NOTES  ON  THE  SURGERY 


OK    T1IK 


WAR  IN  THE  CRIMEA, 


WITH    REMARKS    ON 


THE  TREATMENT  OF  GUNSHOT  WOUNDS. 


BY 

GEORGE  H.  B.  MACLEOD,  M.D.,  F.R.C.S., 

FORMERLY   SURGEON  TO   THE   CIVIL   HOSPITAL   AT  SMYRNA,  AND  TO  THE  r.ENERAL  HOSPITAL 

IN    TAMP   BEFORK   SEBASTOPOLJ 
LECTURER   ON    MILITARY   SURUERY    IN   ANDERSON'S   UNIVERSITY,  GLASGOW,  KTC. 


PHILADELPHIA! 

J.    B.    L  I  P  P  I  N  C  O  T  T    &    CO. 

LONDON:   JOHN  CHURCHILL. 
1862. 


\ 


277 


SIR  JOHN  HALL,  K.C.B.,  M.D.,  F.R.C.S., 

1XSIM;CTOR-<;F,NF.HAI.    OF    HOSPITALS,  AND    1'RIXCIl'AL   MKDICAI,    OF:  ll'KU 

OF    THK    A  It  MY    WHICH     SERVED     IN'    THE    CHIMF.A, 

KTC.   ETC.   ETC. 


DF.AR  SIR:— 

The  permission  to  dedicate  this  book  to  you,  is  to  me  pecu- 
liarly gratifying. 

I  am  glad  to  avail  myself  of  the  opportunity  thus  afforded, 
both  of  bearing  my  humble  testimony,  as  a  civilian,  to  the  un- 
wearied assiduity  and  admirable  skill  displayed  in  the  Crimea  by 
the  Medical  Staff,  of  which  you  were  the  distinguished  chief;  and 
also  of  expressing  my  deep  sense  of  the  considerate  kindness 
|  which  I  have  at  all  times  received  from  yourself  personally,  more 
especially  while  attached  under  your  command  to  the  General 
Hospital  in  Camp. 

I  have  the  honor  to  remain, 

Your  faithful  Servant, 

GEORGE  H.  B.  MACLEOD. 


ST.  YINCKNT  STRRKT,  GLASGOW, 
Ma  ii.  Is.VS. 


M 190244 


PREFACE. 


No  account  of  the  surgical  results  of  the  war  in  the 
Crimea  has  as  yet  appeared,  the  only  attempt  to  supply  the 
desideratum  being,  so  far  as  the  author  knows,  some  papers 
contributed  by  himself  in  1 855-56  to  the  Edinburgh  Medi- 
cal Journal.  These  being  written  hurriedly  from  camp, 
were  of  course  unrevised  by  the  writer  when  going  through 
the  press,  hence  the  existence  in  them  of  many  errors ; 
while  some  of  their  statistics,  although  carefully  compiled 
by  the  authorities  in  camp,  have  been  found,  by  comparison 
at  home,  to  be  inaccurate.  However,  as  these  statistics 
were  supposed  to  represent  the  results  obtained  during  the 
entire  war,  while  those  now  published  only  refer  to  the 
latter  half,  it  is  not  improbable  that  they  are  more  nearly 
correct  than  they  thus  appear  to  be.  It  is,  therefore, 
thought  that  the  following  outline  may  not  be  unaccepta- 
ble to  the  profession.  It  was  printed  several  months  ago, 
but  its  publication  was  delayed,  in  order  to  obtain  the 
obvious  advantages  afforded  by  the  government  statistics. 
These,  so  long  expected,  have  only  just  been  finished,  and 

1*  (v) 


VI  PREFACE. 

a  resume  of  them  will  be  found  in  the  Appendix  to  this 
volume. 

The  author,  though  for  many  reasons  regretting  the  de- 
lay which  has  taken  place  in  submitting  the  following  pages 
to  the  public,  is  gratified  however  to  find  that  his  views 
and  deductions  have  been  so  completely  confirmed  by  the 
Government  Report,  and  by  the  work  of  M.  Scrive,  both 
of  which  have  appeared  since  his  book  has  been  printed. 

It  is  with  great  deference  that  this  little  work  is  given 
to  the  public ;  but  the  writer  does  so  under  the  conviction 
that  some  record  of  our  surgical  experience  in  the  East 
is  desirable,  and  he  bases  his  own  claim  to  a  fair  and  im- 
partial hearing,  simply  on  his  having  had  the  good  fortune 
to  see  so  much  of  the  surgery  of  the  war,  first  at  Con- 
stantinople and  Scutari  during  the  greater  part  of  the 
early  period  when  the  patients  were  chiefly  treated  there, 
and,  latterly,  in  the  Crimea  during  the  last  year  of  the 
campaign,  when  few  cases  left  camp  unconcluded. 

The  Crimean  war,  with  its  hardships  and  triumphs,  has 
passed  into  the  calm  page  of  history,  and  remains  only  in 
its  stirring  memories  to  those  who  took  part  in  it.  Never, 
perhaps,  did  any  campaign  attract  so  great  a  share  of  the 
world's  attention,  or  engage  so  much  of  its  sympathies; 
and  never  again,  perhaps,  will  such  a  concurrence  of  po- 
litical circumstances  bring  together  as  friends  or  foes  so 
many  nationalities.  England  enlisted  with  heart  and  hand 
in  the  contest,  and,  it  is  to  be  hoped,  has  gained  much  from 


PREFACE.  VII 

the  experience  it  brought,  as  her  future  will,  in  no  small 
degree,  depend  on  the  use  that  is  made  of  this  dear-bought 
experience. 

But  this  great  war  has,  unfortunately,  added  little  to  our 
medical  knowledge.  Its  short  duration  prevented  this;  yet 
it  has  shown  us  wounds  of  a  severity,  perhaps,  never  before 
equaled ;  it  has  enabled  us  to  observe  the  effects  of  missiles 
introduced  for  the  first  time  into  warfare ;  it  has  afforded  us 
an  opportunity  of  watching  how  dyscrasial  disease  may 
complicate  injuries,  and  render  skill  abortive;  and  it  has 
helped  us  to  observe  the  development  of  those  "diseases 
of  circumstances"  which  may  sweep  away  an  array  with- 
out any  other  weapon.  Besides,  every  such  war  must 
furnish  some  surgical  facts  which  are  worthy  of  being 
chronicled,  and  must  afford  the  surgeon  some  lessons  which, 
without  adding  to  his  knowledge  much  that  is  absolutely 
new,  are  yet  worthy  of  being  remembered.  A  great  war,  in 
short,  is  a  great  epoch  in  the  onward  march  of  surgical 
science,  when  the  slowly  elaborated  teachings  of  civil  life 
are  tested  on  a  grand  scale  in  the  presence  of  representa- 
tives from  every  school. 

If  attentively  sought,  and  carefully  systematized,  the  ex- 
periences which  are  obtained  in  the  field  might  become  the 
most  reliable  and  useful  which  can  be  anywhere  collected, 
as  nowhere  are  the  circumstances  which  modify  results  more 
easily  traced,  or  more  uniform  in  their  influence.  Unfor- 
tunately, however,  the  vicissitudes,  hardships,  and  uncer- 


Vli  PREFACE. 

tainties  of  a  campaign  present  difficulties  of  no  small 
moment  to  the  collection  and  arrangement  of  observations. 
The  numerous  duties  which  devolve  on  the  military  surgeon 
prevent  that  close  attention  being  paid  to  purely  profes- 
sional questions  which  would  be  requisite  for  the  establish- 
ment of  accurate  conclusions,  while  the  constant  shifting  of 
patients  from  one  hospital  station  to  another  occasions  the 
loss  or  interruption  of  records  bearing  on  the  treatment  of 
disease  and  injury. 

The  shortness  and  abrupt  termination  of  the  war  were 
unquestionably  a  great  loss  to  the  advancement  of  surgery, 
however  great  was  the  gain  otherwise  to  humanity.  We 
had,  at  its  close,  just  overcome  the  preliminary  difficulties 
to  be  anticipated  by  a  State  long  at  peace,  and  whose  mili- 
tary organization  was  defective ;  and  when  we  might  rea- 
sonably have  expected,  had  there  been  another  campaign, 
to  have  garnered  something  valuable  from  its  very  miseries 
and  sufferings.  But  just  when  in  a  position  to  investigate 
many  questions  with  precision  and  advantage,  the  opportu- 
nity passed  away. 

The  value  to  be  attached  to  the  statistics  of  any  war 
must  be  left  to  the  reader.  The  writer  believes  that  those 
having  reference  to  that  in  the  Crimea  are  as  correct  as 
any  can  be  which  are  collected  under  such  circumstances. 
All  the  figures  given  in  the  body  of  the  book,  except  when 
otherwise  stated,  refer  merely  to  the  period  after  April  1, 
1855,  as  it  was  found  impossible  to  compile  them  with  any 


PREFACE.  IX 

accuracy  for  the  previous  period.  In  this  way  a  very  large 
number  of  the  wounded,  and  very  many  operations,  are  not 
included  in  these  figures ;  and  hence,  too,  why  a  different 
bearing  must  be  given  to  many  of  the  questions  discussed 
than  these  figures  will  warrant.  Thus,  for  example,  the 
writer  has  himself  seen  more  cases  of  some  operations  per- 
formed in  the  East  than  appear  in  the  returns.  It  was 
thought  better,  therefore,  to  restrict  the  statistical  enumera- 
tion to  the  period  whose  records  were  correct — although  it 
is  always  to  be  remembered  that  what  was  true  of  the  latter 
part  of  the  war  is  by  no  means  substantiated  by  the  experi- 
ence of  the  first  part. 

The  writer  has  to  acknowledge  with  gratitude  his  obliga- 
tions to  Dr.  Smith,  Director-General,  not  only  for  supplying 
him  with  the  figures  contained  in  the  body  of  this  book,  but 
also  for  affording  him  free  access  to  the  reports  on  the  China 
and  Indian  wars. 

To  Deputy-Inspector  Taylor,  C.B.,of  Chatham,  and  Pro- 
fessor Tholozan,  of  the  Yal  de  Grace,  now  first  physician 
to  the  Shah  of  Persia,  the  writer  is  under  many  and 
deep  obligations,  as  well  as  to  Professors  Mounier  and 
Legouest,  of  the  Yal  de  Grace,  who  kindly  communicated 
the  details  of  their  service  at  Constantinople.  The  writer 
would  also  express  his  thanks  to  the  many  friends  who  have 
supplied  him  with  notes  of  cases,  some  of  which  are  given 
in  the  following  pages  as  illustrations  of  the  questions  dis- 
cussed. 


X  PREFACE. 

The  value  of  surgery  is  nowhere  so  appreciated  as  on  the 
field  of  battle,  and  the  author  rejoices  to  acknowledge  how 
nobly  our  art  is  represented  by  the  present  race  of  military 
surgeons.  In  guarding  the  health,  treating  the  wounds  and 
sicknesses  of  his  fellow-soldiers,  the  surgeon  must  truly  par- 
ticipate in  their  glories  and  triumphs.  "En  les  arrachant 
aux  dangers  de  leurs  blessures,"  says  the  famous  Percy, 
"leurs  triomphes  deviennent  notre  ouvrage ;  la  vie  qu-ils 
tiennent  de  nous,  nous  associe  en  quelque  facon  a  leur 
gloire ;  et  chaque  service  que  re9oit  d'eux  la  patrie,  est  un 
present  dont  elle  est  encore  redevable  a  nos  soins." 


CONTENTS. 


CHAPTER  I. 

The  History  and  Physical  Characters  of  the  Crimea— Its  Climate 
and  Geology— The  Changes  of  the  Seasons  during  the  Occu- 
pation of  the  Allies — The  Steppe  Lands  of  the  Interior — 
Vegetation  and  Resources  of  the  Country — The  Natives  and 
their  Diseases v 13 

CHAPTER  II. 

Drainage  of  the  Camp—Water  Supply — Latrines — Food — Cook- 
ing— Fuel- — Clothing — Housing — Duty — Effects  of  all  these 
combined  on  the  Health  and  Diseases  of  the  Soldiers — Hos- 
pitals— Distribution  of  the  Sick — Nursing,  Male  and  Female 
—Transport 30 

CHAPTER  III. 

The  Campaign  in  Bulgaria,  and  its  Effects  on  the  subsequent 
Health  of  the  Troops — -The  Diseases  which  appeared  there, 
and  during  the  Flank  March,  as  well  as  afterward  in  the 
Camp  before  Sebastopol 63 

CHAPTER  IV. 

Distinction  between  Surgery  as  practiced  in  the  Army  and  in 
Civil  Life— Soldiers  as  Patients,  and  the  Character  of  the 
Injuries  to  which  they  are  liable — Some  Peculiarities  in  the 
Wounds  and  Injuries  seen  during  the  late  War 80 

CHAPTER  V. 

The  "Peculiarities"  of  Gunshot  Wounds,  and   their   General 

Treatment 98 

(xi) 


XII  CONTENTS. 

CHAPTER  VI. 

The  Use  of  Chloroform  in  the  Crimea — Primary  and  Secondary 
Hemorrhage  from  Gunshot  Wounds — Tetanus — Gangrene — 
Erysipelas — Frost-bite 123 

CHAPTER  VII. 
Injuries  of  the  Head • 160 

CHAPTER  VIII. 

Wounds  of  the  Face  and  Chest 198 

/ 

CHAPTER  IX. 

Gunshot  Wounds  of  the  Abdomen  arid  Bladder 227 

CHAPTER  X. 
Compound  Fracture  of  the  Extremities 248 

CHAPTER  XI. 

Gunshot  Wounds  of  Joints — Excision  of  Joints,  ate 275 

CHAPTER  XII. 
Amputation 318 


APPENDIX. 

A — The  Geology  of  the  Crimea 355 

B — Therm ometric  Observations 357 

C— The  Weight  and  Nutritive  Value  of  the  Soldier's  Ration  .     .  360 

D— Return  of  Duty  in  the  Crimea 361 

E — The  Routine  of  Duty  in  Particular  Regiments 361 

F— Table  of  Weight  of  Balls  used  by  the  Belligerents      .     .     .  3<  3 
G — Tables  showing  the  Mortality  following  the  greater  Ampu- 
tations for  Gunshot  Wounds  and  Accidents 3G6 

H — Resume  of  M.  Scrive's  Work  on  the  French  Losses  in  the 

Crimea 368 

I — Resume  of   the    Report  of  the    British   Government  on   the 

Surgery  of  the  War  in  the  Crimea 372 


NOTES 

ON    THE 

SURGERY  OF  THE  CRIMEAN  WAR, 

ETC.  ETC. 


CHAPTER   I. 

The  History  and  Physical  Characters  of  the  Crimea — Its  Climate  and 
Geology — The  Changes  of  the  Seasons  during  the  Occupation  of  the 
Allies — The  Sti-ppe-Lands  of  the  Interior — Vegetation  and  Resources 
of  the  Country — The  Nlitives,  and  their  Diseases. 

As  special  reference  is  made  in  the  following  pages  to 
the  diseases  which  prevailed  in  the  British  array  during  its 
occupation  of  the  Crimea,  and  to  the  marked  influence 
exercised  by  its  climate  on  wounds,  it  may  not  be  deemed 
either  irrcvalent  or  uninteresting  to  make  some  preliminary 
remarks,  however  brief  and  fragmentary,  on  the  history  and 
physical  character  of  the  Crimea  itself. 

The  Black  Sea  (Pontus  Euxinus)  and  the  countries  which 
bordered  it  were,  in  the  ancient  Greek  and  Roman  mind, 
more  associated  with  all  that  was  gloomy  and  horrible,  than 
any  other  portion  of  the  world.  Their  poets  shrouded 
these  regions  in  blackest  darkness,  and  peopled  them,  like 
Milton's  chaos,  with  all  "monstrous,  all  prodigious  things;" 
"Gorgons,  and  Hydras,  and  Chimeras  dire;"  or,  at  the 
best,  with  monsters — in  human  form,  but  strangers  to  human 
sympathies — ruthless  and  murderous,  sacrificing,  to  a  god- 
dess as  sanguinary  as  the  Bowhanie  of  the  East,  every 
unfortunate  mariner  that  chanced  to  be  cast  on  their  rugged 

2  13) 


11  SUlWEilY    OF   THE    CRIMEAN    WAR. 

coast.*  The  Laestrigones,  Cimmerians,  and  Tauri,  by  whom 
the  Chersonesus  Taurica  or  modern  Crimea  was_peopled, 
were  to  the  ancient  mind  the  very  type  of  all  that  was 
savage  and  relentless,  and  the  peculiarly  bloody  rites  of 
their  worship,  have  engaged  the  attention  of  poets,  alike 
ancient  and  modern.  Euripides,  in  his  "Iphigenia  in 
Taurid,"  has  immortalized  the  name  of  the  cruel  priestess 
who  presided  over  these  horrid  observances ;  and  both 
Goethe  and  Racine  have  transferred  her  evil  fame  to  their 
respective  languages.  JEschylus  has  bound  the  tortured 
Prometheus  to  some  rock  of  this  precipitous  coast,  and 
opens  his  great  tragedy  with  lines  which  convey  to  us  the 
distance  and  loneliness  which  he  attached  to  the  scene  of 
his  hero's  prison  ;f  and  the  Tristia  of  Ovid  has  rendered 
familiar  to  all  readers  of  Latin,  the  dismay  and  despair 
with  which  that  poet  regarded  his  fate  when  doomed  to 
dwell  on  the  opposite  shore. 

It  might  be  expected  that  a  region  associated  with  such 
horrors  and  dangers,  natural  and  supernatural,  should  form 
the  poet's  favorite  scene  for  adventures  and  achievements 
transcending  the  ordinary  experience  and  prowess  of  man. 
Accordingly,  the  Crimea  occupied  of  old  the  place  given 
to  enchanted  castles  and  dragon-guarded  palaces  in  the 
romances  of  the  middle  ages,  where  the  most  redoubted 
Jieroes  were  to  signalize  superhuman  bravery,  faith,  and 
endurance.  Here  the  Argonauts  triumphed  over  difficul- 
ties insurmountable  to  men  of  common  mould;  here  Pylades 
and  Orestes  met  the  crowning  adventure  of  their  arduous 
course ;  and  here  it  was,  according  to  the  opinion  of  many 

*  Virgil,  Georg.  lib.  iii.  v.  349,  et,  ss. 

Semper  hyems,  semper  spirantis  frigora  Cauri. 

Turn  Sol  pallentes  haud  unquam  discutit  umbras. 
See  also  Ovid's  Metam.,  lib.  viii   v.  788. 


THE    HISTORY   OF   THE   CRIMEA.  15 

scholars,  that  Ulysses  passed  through  the  severest  ordeals 
encountered  during  his  many  weary  wanderings.* 

But  passing  by  poetic  myth  and  legend,  we  find,  even 
long^  before  the  historic  period,  some  indications  of  the 
habits  of  the  occupants  of  the  Crimea  in  the  rocks  of  its 
valleys,  as  legible  to-day  as  they  were  thousands  of  years 
ago.  The  strange  dwellings  excavated  in  the  chalk  cliffs, 
and  universally  attributed  to  the  Troglodytes,  clearly  prove 
that  that  people  belonged  to  one  of  the  great  Scythian 
families,  which  at  one  period  overspread  the  whole  north- 
east of  Asia  and  Europe.  Then  written  history  tells  us, 
that  after  the  Scythians,  the  adventurous  and  colonizing 
Greeks  occupied  the  Crimea,  carrying  with  them  the  enrich- 
ing power  of  their  commerce,  and  the  refining  influences  of 
their  civilization. 

The  flourishing  establishments  of  the  Milesians  along  the 
south  coast  (B.C.  500)  and  the  powerful  republic  of  Cher- 
son  on  the  southwest  became  the  marts  where  the  corn  of 
the  Crimean  plains — then  richly  productive  from  careful 
cultivation — was  exchanged  for  the  luxuries  and  delicacies 
of  Greece.  But,  more  than  this,  costly  furs,  rare  spices, 
curiously  embroidered  cloths,  collected  over  a  wide  area,  as 
well  as  immense  quantities  of  fish,  were  exported  from  the 
harbors,  and  the  art-treasures  of  Athens  and  of  Corinth 
eagerly  purchased  in  return. 

The  resistless  progress  of  Rome  toward  universal  con- 
quest destroyed  the  territorial  power  of  Greece,  and  neces- 
sarily weakened  her  colonies  and  dependencies,  however 
distant.  We  accordingly  find  that  the  Greek  cities  of  the 
Crimea  were,  shortly  after  this  period,  subjugated  by  the 
great  Mithridates  of  Pontus,  and  deprived  of  their  pre- 
eminence, which  for  many  centuries  they  did  not  regain. 
Mithridates  was,  after  a  most  heroic  and  long-continued 
struggle  with  Rome  in  the  very  zenith  of  her  military  great- 

*  See  especially  the  able  work  of  Dubois  de  Montpereux. 


16  SURGERY    OF   THE    CRIMEAN   WAR. 

ness,  at  length  overthrown,  (B.C.  64;)  and  the  Crimea,  with 
his  other  dominions,  fell  under  the  sway  of  the  empire. 

The  country  enjoyed  consideration  for  a  long  time  there- 
after, as  guarding  the  Euxine  from  the  Sarmatians,  and 
other  northern  tribes,  who  eagerly  sought  its  waters  as  the 
highway  to  the  rich  and  soft  climes  along  its  southern  bord- 
ers. At  length,  however,  the  Goths  effected  what  had 
defied  the  Sarmatians.  Without  dwelling  on  the  romantic 
story,  which  says  that  their  great  ancestor,  Odin,  fled  from 
the  banks  of  Azof  to  escape  the  fetters  of  all-conquering 
Home,  and  on  the  shores  of  the  Baltic  vowed  that  he 
would  rear  a  race  of  warriors  who  should  spoil  the  spoiler, 
it  is  certain  that,  at  the  Christian  era,  the  Goths  were  a 
powerful  people,  occupying  the  modern  Prussia  and  sur- 
rounding districts.  Year  after  year,  and  age  after  age, 
they  fought  with  the  Romans,  always  pushing  southward 
and  eastward.  In  course  of  time,  they  advanced  from  the 
Baltic  as  far  to  the  southeast  as  the  shores  of  the  Euxine. 
Many  and  fierce  were  their  combats  with  the  Romans,  but, 
though  occasionally  compelled  to  yield  to  the  remnant  of 
disciplined  valor  still  clinging  to  the  old  legionaries,  their 
dauntless  bravery  secured  to  them  many  victories.  They 
turned  their  course,  however,  from  the  Danube  to  the 
Borysthenes,  and  after  occupying  the  fertile  plains  of  the 
Ukraine  for  a  time,  they  again  sallied  forth  toward  the 
south.  They  speedily  subdued  the  Crimea — the  Tauric 
Chersonese,  or  the  kingdom  of  Bosphorus,  as  the  peninsula 
was  then  indifferently  called — and  thence  quickly  pushed 
their  way  into  the  richest  and  fairest  regions  of  the  empire. 
It  is  said  that  traces  of  Gothic  features,  and  very  faint  traces 
of  the  Gothic  language,  are  still  to  be  discerned  among  the 
inhabitants  of  the  Crimean  mountains.  They  have,  how- 
ever, left  no  other  trace  of  their  occupancy ;  and  for  many 
centuries  nothing  is  known  of  the  history  of  the  country 
except  that  it  was  repeatedly  ravaged  by  various  tribes  who, 


THE    HISTORY   OF   THE   CRIMEA.  IT 

during  the  "great  migration  of  nations,"  swept  like  succes- 
sive waves  from  the  northeast  to  the  southwest. 

At  length,  in  the  thirteenth  century,  a  band  of  the  Mon- 
golian Tartars,  known  as  the  Khazars,  fixed  themselves  per- 
manently in  it,  and  gave  it  the  name  of  Crim-Tartary.  The 
majority  of  its  inhabitants  at  the  present  day  are  undoubt- 
edly their  descendants.  During  this  period  a  bright  gleam 
of  prosperity — soon,  however,  to  be  again  quenched  in  bar- 
baric darkness — shone  upon  the  Crimea. 

The  Genoese,  through  the  fourteenth  century,  rapidly  ris- 
ing to  importance  from  their  commercial  skill  and  maritime 
enterprise,  perceived  the  importance  of  the  country  as  a  link 
of  communication  between  Europe  and  Asia,  and  purchased 
permission  from  the  Khans  to  establish  mercantile  factories 
on  the  coast.  These  speedily  became  flourishing  marts  of 
trade,  where  the  goods  of*  northern  Europe,  of  Asia  Minor, 
of  Persia,  and  even  of  the  distant  Indies,  were  collected 
and  exchanged.  Kaffa,  now  Theodosia,  originally  a  Mile- 
sian city,  rose  to  great  wealth  and  power,  containing  a 
population  of  more  than  100,000,  and  in  many  respects 
vying  with  the  proud  Italian  city  herself.  These  merchant 
princes  have  passed  away;  but  even  now,  along  the  sound- 
ing' shores,  and  far  amid  the  mountains,  in  lonely  valleys 
and  on  lofty  hills,  there  remain  many  traces  of  this  remark- 
able people  in  the  nodding  towers  of  crumbling  fortresses, 
and  the  massive  fragments  of  more  enduring  and  noble 
architecture  which  have  stood  through  many  ages  in  soli- 
tary desolation. 

Kaffa  continued  to  grow  and  to  prosper  for  about  a  cen- 
tury and  a  half.  At  the  close  of  that  period  it  suffered  the 
doom  inflicted  on  greater  and  more  powerful  cities  by  a 
ruthless  destroyer.  Mahomet  II  ,  the  Turkish  sultan,  as  is 
well  known  completed  the  destruction  of  the  eastern  empire 
by  the  capture  and  desolation  of  Constantinople  in  1553. 
About  ten  years  thereafter,  he  overthrew  the  noble  Trebi- 
zond,  and,  still  unsated,  he  in  the  year  1575  subjected  Kaffa 


18  SURGERY   OF    THE   CRIMEAN    WAR. 

to  the  same  melancholy  fate.  He  spared  the  buildings,  but 
carried  more  than  40,000  of  the  inhabitants  to  Constan- 
tinople in  order  to  repeople  its  wastes,  and  took  with  him 
many  shiploads  of  gold  and  silver,  and  the  richest  merchan- 
dise. The  remaining  inhabitants  were  scattered  or  de- 
stroyed. Kaffa  soon  became  an  absolute  desert,  and  the 
other  Genoese  cities  speedily  shared  its  decay. 

Mahomet  perceived  his  error,  and  sought  by  means  of 
Yenetian  settlers,  to  whom  he  offered  the  highest  commer- 
cial privileges,  to  restore  the  prosperity  which  he  had  so 
wantonly  destroyed;  but  all  history  shows  that  even  the 
most  powerful  despot  cannot  restore  a  city  once  brought  to 
ruins,  and  the  experience  of  Mahomet  powerfully  confirms 
the  general  truth.  Even  Constantinople  did  not  revive,  and 
Kaffa  utterly  perished  in  his  hands. 

For  another  period  of  about  two  hundred  years  the 
Crimea  languished  under  Turkish  rule.  About  the  year 
1760,  Catherine  II.  of  Russia,  seeing  its  importance  as  an 
outwork  whence  to  push  conquest,  annexed  it  to  the  Rus- 
sian empire;  and  that  her  policy  has  not  been  forgotten  by 
her  successors,  has  been  too  fearfully  manifested  to  all  Europe 
in  the  late  great  struggle. 

In  the  late  war  modern  Europe  has  for  the  first  time  made 
the  Crimean  plains  the  battle-ground,  and  I  doubt  not  that 
the  acts  of  heroism  to  which  they  have  been  witness,  the 
patient  endurance  and  stern  bravery  which  have  been  there 
displayed,  will  print  the  name  of  that  land  more  indelibly 
on  the  page  of  history  than  could  all  the  transient  glories 
of  rival  cities  in  days  long  past,  or  the  barbaric  splendor  of 
the  many  conquerors  who  have  successively  ruled  and  passed 
away  from  it  forever.  At  some  distant  day,  when  the 
memory  alone  remains  of  the  brave  deeds  which  were  there 
performed,  the  husbandman  will  perhaps  turn  with  the  same 
astonishment  to  gaze  on  the  rusty  and  broken  weapon,  or 
marble  fragment,  with,  to  him,  unknown  inscription,  which 
he  has  laid  bare  with  his  plow,  as  we  did  when  we  drove  our 


PHYSICAL   CHARACTER   OF    THE   CRIMEA.  19 

approaches  over  mosaic  pavements,  and  by  long-buried 
hearths,  ana  deep  among  graceful  capitals  and  shafts  of 
shining  marble,  which  alone  remain  to  tell  of  the  luxury 
and  magnificence  of  departed  nations.* 

The  Crimea  is  a  peninsula  of  a  quadrilateral  shape,  hav- 
ing a  superficies  of  between  10,000  and  11,000  square  miles, 
lying  between  the  latitudes  43°  40'  and  45°  40'  N.,  and  in 
E.  long.  34°  30'  to  35°  30'.  It  is  surrounded  on  all  sides 
by  water.  The  Black  Sea  washes  its  shore  on  three  sides, 
while  the  Sivashe,  or  Putrid  Sea,  and  the  Sea  of  Azof  com- 
plete its  boundaries.  Although  connected  to  a  great  con- 
tinent by  a  very  narrow  isthmus,  and  encircled  by  water  on 
all  sides,  yet  its  near  neighborhood  to  the  mainland  prevents 
its  having  a  purely  insular  cjimate.  It  is  by  this  peculiar 
position  that  we  explain  the  great  variation  of  the  climate. 
The  oscillations  which  take  place  between  the  two  great 
climatic  types — the  continental  and  insular — impress  them- 
selves strongly  on  the  attention,  and  are  extremely  difficult 
to  reduce  to  fixed  principles. 

The  southern  coast,  bold,  steep,  and  inhospitable,  has 
been  torn  and  split  by  volcanic  action,  and  indented  in  vari- 
ous places  into  deep  and  narrow  harbors.  The  great  force 
of  that  volcanic  upheaving  which  elevated  this  coast  is  dis- 
tinctly evidenced  all  along  the  shore.  One  great  wave  of 
burning  rock  extends  from  east  to  west  for  a  hundred  miles, 
lying  close  to  the  sea,  and  attaining  an  elevation  of  from 
800  to  1000  feet.  From  its  elevated  crest  the  country  slopes 
away  north,  in  green  grassy  plains,  which  gradually  melt 
into  the  wide  expanse  of  the  steppes. 

At  Balaklava,  conglomerate,  mixed  with  coarse  sand- 
stone and  variegated  marble,  lies  heaped  up  in  wild  confu- 
sion, forming  vast  masses  which  overhang  the  harbor.  East 


*  The  French  established  their  approaches  and  batteries  against 
the  Quarantine  bastion  through  the  ruins  of  the  ancient  city  of 
Krr.son. 


20  SURGERY    OF    THE    CRIMEAN    WAR. 

of  this  point,  rocks,  formed  chiefly  of  tertiary  limestone  and 
colored  marbles,  throw  their  vast  bulk  many  hundred  feet 
into  the  air,  or  lie,  like  the  Aia-dagh,  or  "Bear  Mountain," 
in  huge  detached  masses  far  in  the  sea.  Jets  of  porphyry 
are  often  seen  to  fill  the  rents  in  the  perpendicular  face  of 
these  rocks,  and  at  intervals  the  long  dormant  craters  of 
extinct  volcanoes  are  met  with.  To  the  westward  of  Balak- 
lava,  toward  Cape  Kersonesus,  basalt,  amygdaloid,  and  por- 
phyry are  seen  under  the  tertiary,  or  steppe  limestone  of  the 
plateau  next  the  sea. 

The  calcareous  composition  of  most  of  the  mountains 
along  the  coast  is  plainly  betrayed  by  their  rounded  sum- 
mits. The  sub-lying  rock  of  the  inland  plains  is  limestone, 
chalk,  and  green  sand,  while  in  the  valleys  especially,  the 
horizontal  beds  of  these  latter  strata  are  particularly  con- 
spicuous. The  precious  metals  are  said  to  have  been  at 
one  time  found  in  the  rocks  of  the  coast;  but  recent  inves- 
tigation has  failed  to  discover  them.* 

The  appearance  of  the  country  some  short  distance  from 
the  sea  is  very  curious  and  striking.  Bold  promontories, 
which  look  like  sea  capes  left  by  the  tide,  occur  in  frequent 
repetition,  standing  amid  encircling  valleys,  with  their  per- 
pendicular faces  always  to  the  south,  and  sloping  gradually 
to  the  north.  Such  inland  promontories,  from  the  ease 
with  which  they  can  be  isolated  and  defended,  have  served 
at  all  periods  of  the  country's  history  as  natural  fortresses 
for  the  inhabitants,  and  have  proved,  as  in  the  case  of  the 
famous  "Mangoup  Kali,"  almost  impregnable  encampments. 

The  portion  of  the  Crimea  on  which  stand  the  "blood- 
stained "  ruins  of  Sebastopol,  and  on  which  the  allies  were 
so  long  encamped,  forms  the  lesser  peninsula  which  projects 
from  the  greater  at  its  southwest  extremity.  It  is  thus  the 
lesser  Chersonesus,  or  the  Chersonesus  Heracleotica  of  the 
ancients,  deriving  its  name  from  Heraclea,  the  native  city  of 

*  See  Appendix  A. 


PHYSICAL   CHARACTER   OF   THE   CRIMEA.  21 

V 

the  colonists,  who  built  Kerson  on  its  extremity.  It  is 
bounded  by  the  sea,  the  harbor  of  Sebastopol,  the  Tclier- 
naya  River,  which  empties  itself  into  the  head  of  that  arm 
of  the  sea,  and  finally  by  a  deep  and  broad  valley  which 
runs  across  the  neck  of  the  peninsula  from  the  Tchernaya 
to  Balaklava.  This  piece  of  country,  which  is  of  a  trian- 
gular shape,  measures  some  eleven  miles  from  apex  to  base, 
and  about  nine  miles  in  breadth,  containing  an  area  of 
about  sixty  square  miles.  It  was  at  one  time  divided  from 
the  mainland  by  a  wall  built  by  the  ancient  colonists  to  pro- 
tect themselves  on  the  land  side,  and  which  barrier  ran 
across  the  valley  from  the  River  Tchernaya  to  the  harbor  of 
Balaklava.  Within  this  boundary  an  enormous  city  once 
stood,  containing  as  many  inhabitants  as  the  British  army 
which  more  lately  pitched  their  tents  on  the  site  of  its  ruins. 
From  Cape  Kersonesus,  the  apex  of  the  triangle,  the  land 
of  this  little  peninsula  rises  inland  till  it  reaches  some  high 
cliffs  of  fossiliferous  limestone  which  immediately  overhang 
the  valley,  and  the  river  which,  I  have  said,  constitutes  its 
boundaries. 

The  mountain  chain  which,  I  stated  above,  stretches  along 
the  coast,  strikes  inland  when  it  reaches  Balaklava,  and  runs 
for  some  distance  in  a  northerly  direction,  then  sweeps  round 
to  the  north  side  of  the  grand  harbor  of  Sebastopol,  and 
dips  into  the  sea.  This  mountain  barrier  is  very  precipitous 
on  the  side  facing  the  plateau,  presenting,  below  M'Kenzie's 
farm,  an  almost  perpendicular  face  of  chalk  of  1000  feet  to 
the  summit.  This  range  is  penetrated  by  various  deep  val- 
leys, some  of  which  give  passage  to  copious  streams.  It 
will  be  thus  understood  that  "the  plateau  of  Sebastopol," 
as  it  was  often  called,  upon  which  the  British  and  French 
troops  were  encamped,  and  which  was  the  scene  of  so  much 
suffering  and  heroism,  was  totally  excluded  from  the  shelter 
of  the  mountains,  which,  in  fact,  did  not  approach  within 
miles,  but  were  sufficiently  elevated  above  it,  and  adequately 
near,  to  allow  the  enemy  who  held  them  to  overlook  our 


22  SURGERY  OF  THE  CRIMEAN  WAR. 

whole  position — an  advantage  which  he  turned  to  good 
account.  From  these  circumstances,  the  unprotected  posi- 
tion of  the  camp  to  the  north  and  east,  and  its  complete 
exposure  to  the  sea  on  the  west  and  south,  will  become  at 
once  evident.  It  is  of  consequence  to  keep  this  in  mind,  as 
it  had  a  material  bearing  on  the  climate. 

The  elevation  of  the  plateau  above  the  sea  level  was  not 
great,  being  but  700  or  800  feet  at  its  highest  point.  The 
soil  was  generally  scanty  and  light,  but  here  and  there  it 
consisted  of  a  stiff  clay.  It  was  easily  converted  by  rain 
into  a  most  tenacious  mud,  which  interfered  greatly  with 
progression,  and  was  sufficiently  adhesive  to  wrench  the 
shoes  off  the  horses'  feet.  The  underlying  rock  was,  for 
the  most  part,  a  porous  stratified  limestone  dipping  west- 
ward, and  underlaid  toward  Inker-man  by  nummulitic  lime- 
stone. From  the  lie  of  some  of  the  deep  non-porous  strata 
the  water  was  conducted  along  them  into  the  deeper  inden- 
tations and  valleys  which  mark  the  surface  of  the  plateau, 
and  there  especially  the  soil  was  generally  kept  damp  and 
tenacious.  Along  the  sides  of  the  numerous  ravines  which 
broke  the  surface  in  their  course  toward  the  sea,  the  rocks 
cropped  out  in  rough  masses,  and  strewed  the  hollows  with 
detached  fragments. 

The  valley  on  which  the  harbor  of  Balaklava  opens,  and 
which  I  described  above  as  crossing  the  base  of  the  plateau, 
consists  of  schists  on  the  side  next  Balaklava,  and  farther 
on,  toward  the  Tchernaya,  of  limestone.  This  valley  is 
about  four  miles  and  a  half  long  by  two  broad,  and  is 
divided  from  the  valley  of  the  Tchernaya^by  the  Fedoukine 
heights — chalky  elevations  of  some  400  or  500  feet,  on 
which  one  division  of  the  French  army  was  stationed,  and 
along  the  base  of  which  the  battle  of  the  Tchernaya  was 
fought.  The  river,  which  is  not  of  any  size,  flows  close 
below  these  heights  over  a  bed  of  marl  and  pebbles.  Beyond 
it,  a  plain,  averaging  about  three  miles  in  breadth,  stretches 
to  the  foot  of  the  M'Kenzie  heights. 


PHYSICAL   CHARACTER   OF    THE    CRIMEA.  23 

The  line  which  marks  the  mean  temperature  of  the 
Crimea  in  January  corresponds  to  that  of  Iceland,  (32°,) 
while  its  July  line  bisects  Madrid,  (72°.)  The  mean  for  the 
whole  year  corresponds  to  that  of  the  Isle  of  Wight,  (about 
50°,)  which  is  five  degrees  farther  north  in  latitude. 

There  are  in  the  Crimea  two  regions  which  possess  very 
distinct  and  dissimilar  climates.  I  refer  to  the  narrow  belt 
of  sea-coast  which  is  inclosed  on  its  northern  side  by  the 
Tauric  chain,  and  of  which  I  made  mention  before,  and  the 
much  greater  division  of  the  peninsula  which,  excluded 
from  the  embrace  of  these  mountains,  lies  totally  unsheltered 
from  the  cold  winds  that  blow  so  unrelentingly  at  certain 
seasons.  In  this  latter  division  lies  the  plateau  of  Sebas- 
topol. 

About  100  miles  of  coast — nowhere  of  any  considerable 
breadth,  but  at  many  points  a  mere  stripe — is  thoroughly 
protected  by  the  mountain  range  which  borders  it.  This 
chain  throws  the  dreaded  north  and  east  winds  which  deso- 
late the  inland  plains  far  beyond  the  limited  belt,  and  se- 
cures for  it  a  purely  insular  climate,  little  varying,  and  of  the 
most  delicious  mildness.  This  region  is  the  Baias  of  Russia, 
arid  contains  the  magnificent  summer  residences  of  her  no- 
bility. At  Balakluva  the  mountains  cease  to  follow  the 
coast,  but  throwing  one  spur  into  the  sea  run  north  toward 
the  interior,  where  1  before  traced  them.  It  is  this  spur 
which  so  completely  closes  in  these  Elysian  fields  to  the 
Sebastopol  side,  and  which  also  enabled  the  enemy,  from 
the  difficulty  of  the  passes,  to  maintain  their  ground,  while 
the  allied  armies  were  kept  outside  on  the  bare  plateau,  ex- 
posed to  the  unmitigated  fury  of  the  winter's  storm.  Thus 
it  was,  that  within  a  few  miles  as  great  a  difference  of  climate 
was  found  as  commonly  exists  between  the  opposite  sides  of 
a  great  continent,  and  while  the  outposts  of  the  enemy's 
forces  which  occupied  the  southern  littoral  enjoyed  during 
winter  all  the  luxury  of  an  Italian  sky  and  tropical  vegeta- 
tion, our  army  lay  in  the  sweep  of  those  northern  and 


24  SURGERY    OF    THE   CRIMEAN    WAR. 

eastern  blasts  which,  blowing  over  the  vast  frozen  plains  of 
the  interior,  bring  with  them  the  rigor  of  an  Arctic  winter. 

I  have  already  hinted  at  the  great  variableness  of  the 
climate  of  that  part  of  the  Crimea  occupied  by  the  allied 
forces.  This  inconstancy  was  undoubtedly  its  most  striking 
feature.  The  mean  temperature  of  a  week  or  a  month  might 
not,  indeed,  differ  greatly  from  that  of  the  week  or  the  month 
which  preceded  or  followed  it,  but  the  daily  sensible  varia- 
tions were  frequently  very  great.*  At  some  seasons  these 
diurnal  changes  were  more  severe  than  at  others.  Thus,  in 
winter,  something  of  the  following  succession  not  uncom- 
monly occurred  :  A  dark,  "  muggy  morning,"  with,  perhaps, 
a  "  Black  Sea  fog"  rolling  its  heavy,  damp  folds  over  the 
plain,  giving  you,  when  inclosed  in  its  embrace,  a  feeling  that 
resembled  nothing  so  much  as  being  in  the  drying-room  of 
some  large  wash-house,  would  be  succeeded  by  a  splashing 
rain,  a  sharp  hall-storm,  and  an  intense  frost,  all  within  a  few 
hours.  The  alternation  of  frost  and  thaw  was  sometimes 
very  remarkable,  and  it  was  difficult  to  tell  which  would  ulti- 
mately prevail.  A  heavy  fall  of  snow  occurring  during  the 
night  would  have  its  surface  rendered  crisp  and  dusty  by  the 
keen  morning  frost,  and  at  mid-day  be  converted  into  a  deep 
slush  by  the  hot,  sultry  breath  of  the  sea  wind.  Even  so  it 
must  have  been  in  those  dark  and  stormy  days  when  Ovid 
looked  out  from  his  place  of  exile  on  the  wintry  sea,  and 
wrote  his  dreary  account  of  a  Pontic  winter. 

Successive  seasons  appear,  from  the  record  of  travelers, 
to  differ  considerably  the  one  from  the  other.  Cycles,  too, 
of  a  similar  character,  alternate  with  others  of  a  different 
description.  During  the  stay  of  the  allies,  the  first  winter 
was  providentially  much  less  severe  than  the  second,  when 
the  preparations  to  meet  it  were  more  complete.  A  dreadful 
severity  appears  periodically  to  mark  the  cold  season.  Fear- 
ful snow-storms,  greatly  dreaded  by  the  inhabitants,  pass  like 

*  See  Appendix  B. 


V 
PHYSICAL   CHARACTER   OP    THE   CRIMEA.  25 

whirlwinds  of  death  aud  destruction  over  the  exposed  parts 
of  the  country,  and  bury  whole  villages  beneath  their  drifting 
eddies,  while  those  icy  winds,  which  few  who  have  ever  felt 
their  edge  will  forget,  lash  the  unfortunate  traveler  as  with 
stripes  of  scorpions. 

The  transition  from  winter  to  spring  is  very  rapid.  A  few 
days  revolutionize  the  year.  In  1856  this  was  markedly  the 
case.  To  winter's  "ruffian  blasts"  quickly  succeeded — 

"  Those  softer  gales,  at  whose  kind  touch 
Dissolving  snows  in  livid  torrents  lost, 
And  mountains  lift  their  green  heads  to  the  sky." 

Then,  for  a  time,  the  climate  became  delicious.  All  nature 
was  in  a  moment  astir,  and  awoke  suddenly  from  the  long 
winter's  sleep.  We,  too,  "felt  the  spring  in  all  our  pulses." 
Music  was  again  heard  in  the  various  camps,  which  became 
the  scene  of  vigorous  sports  and  healthful  labor.  Even 
through  the  thickly-scattered  fragments  of  the  deadly  shell, 
the  spring  flowers  timidly  pushed  their  gentle  heads;  while 
down  the  little  valleys,  and  by  the  water-courses,  the  crocus 
and  snowdrop,  with  various  orchidaceous  plants,  reminded 
one  of  similar  sheltered  nooks  at  home. 

Summer,  again,  is  for  the  most  part  oppressively  hot.  In 
June,  July,  and  August  the  temperature  ranged  from  80° 
to  100°  on  the  plateau,  and  this,  during  our  occupation,  was 
often  far  more  than  could  be  borne  with  comfort,  protected 
as  we  were  only  by  the  thin  covering  provided  by  cam- 
paigning resources.  It  was  at  this  season  that  the  hated 
sirocco  tainted  the  air  with  its  hot,  oppressive  breath,  which, 
while  it  turned  the  strength  of  the  healthiest  into  feebleness, 
utterly  prostrated  the  poor  invalid.  Then,  too,  the  nauseous 
efiluvia  of  a  great  camp  became  most  obnoxious,  and  the 
loaded  air  refused  to  the  sick  and  languid  that  refreshment 
they  so  greatly  needed.  The  dryncss  of  the  wind  which  so 
oH<jn  prevailed  at  this  season  removed  the  moisture  from 
the  body  as  soon  as  it  was  formed,  and  produced  an  amount 


26  8UEGE11Y    OF    THE    CRIMEAN    WAR. 

of  lassitude  difficult  to  describe.  If  the  nights  had  been 
fresh,  the  effects  produced  on  the  sick  by  this  weather  would 
have  been  less  destructive  than  they  were,  but,  unfortunately, 
the  breeze  often  died  away  at  sunset,  and  rendered  the  even- 
ing hours  very  exhausting.  After  the  unfortunate  assault 
of  the  18th  of  June,  this  circumstance  was  very  marked,  and 
proved  highly  injurious  to  the  wounded.  Dew  appears  but 
little  in  summer — at  least  so  it  was  during  our  stay.  Thun- 
der-storms occurred  occasionally,  preceded  by  whirlwinds, 
which  carried  columns  of  dust  through  the  carnp,  and  filled 
every  corner  with  their  burden.  At  times,  tents  and  huts 
went  down  before  the  suddenness  of  the  assault,  stifling  and 
crushing  the  helpless  sufferers  who  lay  within  them. 

Autumn  again  was  charming.  The  coolness  of  the  morn- 
ings and  evenings,  the  tempered  heat  of  the  mid-day  sun, 
and  the  genial  showers  rendered  the  climate  delightful, 
while  the  beauties  of  sun  and  shade  which  played  in  such 
variegated  richness  over  the  broken  mountains,  and  the 
brilliant  sunsets  which  lit  up  the  many  peaks  with  their 
purple  splendor,  and  threw  their  golden  shafts  far  over  the 
shining  surface  of  the  calm  sea,  gave  camp-life,  at  that 
season,  a  charm  to  which  we  had  previously  been  entire 
strangers.  Notwithstanding  the  many  predictions  to  the 
contrary,  the  health  of  the  troops  did  riot,  at  that  season, 
deteriorate  ;  the  "  Periculosior  a3stas  autunmus  longe  pericu- 
losissimus,"  though  loudly  proclaimed  at  home,  happily 
found  with  us  no  verification. 

Taking  one  season  with  another,  the  climate  of  the  Crimea 
must  be  admitted  to  be  a  fair  one,  especially  when  the  in- 
habitants are  protected  by  well-built  houses.  That  our  army 
suffered  from  very  few  ailments  which  were  directly  referable 
to  the  climate,  says  much  for  its  goodness,  when  it  is  con- 
sidered how  little  it  was  protected  against  the  rigors  and 
vicissitudes  of  such  weather  as  prevailed.  The  officers, 
although  exposed  alike  with  their  men,  yet  suffered  far  less 
from  sickness — a  result  which  can  be  attributed  alone  to  the 


PHYSICAL   CHARACTER    OF   THE    CRIMEA.  27 

better  diet,  the  change  of  clothes,  the  superior  bedding,  and 
freedom  from  manual  work,  which  they  enjoyed.  The  extra- 
ordinary immunity  from  pulmonary  affections  which  existed 
was,  at  least,  remarkable ;  yet,  that  certain  seasons  did  very 
decidedly  impress  their  influence  on  the  wounded,  I  am  ready 
to  maintain.  Of  this,  however,  I  will  speak  more  fully  after- 
ward. 

The  steppe  lands  of  the  interior  present,  in  early  spring,  a 
lovely  scene  of  rolling  plains  of  waving  grass  and  gay  flowers, 
stretching  in  unbroken  verdure  to  the  horizon.  As  the  heat 
increases,  all  this  vegetation,  however,  is  soon  burned  up, 
from  the  soil  being  but  thinly  strewn  over  the  underlying 
tertiary  limestone.  At  midsummer,  the  view  is  dreary  and 
cheerless  enough.  Clouds  of  dust,  carried  by  the  whirling 
currents  of  air,  sweep  over  the  wide,  shadeless  expanse,  and 
the  trembling  mirage  wanders  restlessly,  or  the  "  burian " 
wheels  in  weird-like  flight  before  the  burning  breeze.  No 
mountains  relieve  the  eye,  and  only  the  swampy  salt  lakes, 
which  occur  at  intervals,  break  the  dead  uniformity  of  the 
barren  waste.  An  oppressive  monotony  reigns  everywhere. 
The  brown,  changeless  plain  and  the  brazen  sky  overhead 
continue  ever  the  same ;  not  a  shadow  is  cast  across  the 
horizon,  and  day  sinks  into  night  almost  without  a  twilight. 

Many  of  the  valleys  among  the  mountains  of  the  sea- 
coast  form,  on  the  other  hand,  a  delightful  contrast  to  the 
dull,  dreary  waste  of  the  steppes,  being  very  beautiful,  highly 
cultivated,  and  well  peopled.  The  fields  were  literally 
covered  with  fruit-trees  when  I  first  saw  them  in  spring,  and 
the  neat,  clean  villages  of  the  Tartar  peasants  stood  clus- 
tered round  with  many-colored  blossoms.  Clear,  sparkling 
streams  from  the  overhanging  mountains  watered  the  green 
pastures,  which  looked  like  nothing  so  much  as  a  constant 
succession  of  gardens. 

The  vegetation  of  the  Crimea  differs  much  in  different 
parts.  Along  the  sheltered  south  coast  it  is  almost  tropical. 
Thu  vine  there  grows  in  luxuriance,  and  yields  a  wholesome 


28  SURGERY  OF  THE  CRIMEAN  WAR. 

wine.  The  mulberry,  the  fig,  and  the  olive,  the  pomegranate, 
filbert,  and  walnut,  together  with  the  peach,  the  apple,  the 
pear,  apricot,  and  cherry,  crown  the  hillsides  as  with  a  forest; 
while  rare  flowers  flourish  without  protection  in  the  open  air. 
In  other  parts  of  the  peninsula,  elm,  ash,  and  beech,  together 
with  the  juniper  and  pine,  are  met  with  ;  and  high  up, 
clinging  to  the  precipitous  rocks,  the  Tauric  pine  retains  its 
unstable  footing.  The  wild  rose,  asphodel,  iris,  primrose, 
and  hyacinth  deck  the  ground  at  various  seasons,  and  the 
peony  astonishes  our  English  notions  by  its  size  and  fra- 
grance. 

Game  abounds  in  many  parts  of  the  peninsula.  The  hare 
and  red-legged  partridge,  with  wild  duck  and  snipe,  were 
occasional  and  welcome  guests  within  our  lines.  In  winter, 
the  greater  and  lesser  bustard  and  the  wild  goose  passed  in 
vast  flocks  over  the  camp,  and  were  sometimes  initiated  in 
the  mysteries  of  the  pot-au-feu  by  their  fortunate  captors. 

The  present  natives  of  the  country  are  of  a  mixed  descrip- 
tion. Those  of  the  plains  are  undoubted  Tartars,  with  the 
high  cheek-bones,  far- severed  pig-like  eyes,  and  flat  features 
of  the  Mongolian ;  but  the  inhabitants  of  the  mountain  vil- 
lages appear  of  a  much  more  mixed  race,  and,  not  uncom- 
monly, the  refined  features  of  the  Greek  physiognomy  are 
met  with.  They  appear  a  quiet  inoffensive  race,  honest  in 
expression  of  face,  and  powerful  in  body.  They  are  very 
cleanly  in  their  persons  and  habits,  and  their  villages  are 
generally  models  of  neatness.  Their  houses,  collected  into 
little  knots  in  the  villages,  or  perched  in  the  sheltered  nooks 
of  the  mountains,  though  unpretending,  have  an  air  of  com- 
fort not  often  seen  in  the  East ;  and. the  peaceful  demeanor  of 
the  inmates,  who  crowd  out  to  stare  at  the  foreigner,  seems 
to  belie  their  ancient  character  for  warlike  prowess  and 
ferocity. 

I  could  learn  but  little  of  the  diseases  of  the  inhabitants, 
from  not  knowing  their  language.  Scabies  seemed  not  un- 
common, and  many  were  pitted  with  small-pox.  Deputy- 


PHYSICAL   CHARACTER    OF    THE   CRIMEA.  29 

Inspector  Mowat,  iu  his  report  on  the  Russian  hospitals,  tells 
us,  on  the  authority  of  the  Russian  rnedica'  officers,  that  re- 
mittent fevers  appear  to  be  the  endemic  of  the  Crimea,  and 
that  disease  from  which  the  Tartar  inhabitants  chiefly  suffer. 
Ophthalmia  is  said  to  be  common  in  Sebastopol,  caused 
probably  by  the  fine  limestone  dust  of  the  unpaved  streets, 
arid  the  strong  sunlight.  Though  having  my  attention  fully 
alive  to  it,  I  failed  to  see  any  cases  of  tubercular  elephanti- 
asis, the  "Morbus  Crimensis"  of  Pallas  and  Martins,  and  I 
never  heard  any  one  say  he  had  seen  a  case  in  any  of  the  vil- 
lages. Probably,  if  such  cases  did  exist,  they  would  be  in- 
visible to  the  traveler,  as  the  inhabitants  are  too  well  off  to 
show  their  sick  as  objects  of  charity. 


CHAPTER  II. 

Drainage  of  the  Camp — Water  Supply — Latrines — Food — Cooking — Fuel 
—  Clothing  —  Housing  —  Duty — Effects  of  all  these  combined  on  the 
Health  and  Diseases  of  the  Soldiers— Hospitals— Distribution  of  the 
Sick — Nursing,  Male  and  Female — Transport. 

I  HAVE  endeavored,  in  the  previous  chapter,  to  describe 
the  physical  conformation  of  the  Crimean  peninsula,  and  the 
leading  features  of  the  plateau  on  which  were  established 
the  cantonments  of  the  allied  army.  When  this  plateau  was 
first  occupied,  a  thick  brushwood  covered  a  considerable  part 
of  its  surface  toward  Inkerman.  Most  of  this  underwood 
consisted  of  low  bushes  growing  out  of  the  "stools"  of  for- 
mer trees,  and  was  seldom  of  any  considerable  size.  It  is  a 
well-recognized  fact  that  ground  so  covered,  or  which  has 
been  but  lately  cleared,  forms  a  most  objectionable  position 
for  a  camp,  chiefly  on  account  of  the  moisture  which  is  so 
apt  to  be  retained  by  a  soil  shaded  from  the  sun;  but  in  the 
present  instance  the  evils  which  might  have  followed  the 
enforcement  of  strategic  expediency  in  preference  to  the  dic- 
tates of  medical  prevision,  were  providentially  counterbal- 
anced by  the  elevation,  height,  and  openness  of  the  ground, 
and  the  absence  of  trees  of  any  magnitude. 

The  low  ridges  and  rounded  knolls  which  occurred  in 
frequent  repetition  over  the  plateau  afforded  most  excellent 
sites  for  tents  and  huts.  By  guarding  them  with  a  trench  on 
the  uphill  side,  the  surface  water  was  diverted,  and  the 
ground  which  they  covered  kept  dry.  Advantage  was  taken 
of  the  elevations  to  increase  the  accommodation  and  com- 
fort of  the  tents  by  digging  a  hole  into  their  sides,  over 
which  the  tent  was  pitched.  During  heavy  rains  these  holes 
(30) 


DRAINAGE   OF   THE   CAMP.  31 

were,  however,  sometimes  filled  with  water  by  the  overflow 
of  a  deficient  drain,  and  fatal  consequences  have  followed 
the  use  of  charcoal  fires  in  them,  from  the  weight  of  the  gas 
generated  keeping  the  pit  full  of  a  dangerous  atmosphere.* 
The  chalky  subsoil  of  the  plateau  was  very  conducive  to  the 
health  of  the  camp,  both  from  the  rapidity  with  which  the 
surface  dried,  and  also  from  the  springs  which  it  afforded. 
As,  however,  the  water  flowed  along  the  surface  of  the 
deeper  non-permeable  strata,  and  welled  out  at  those  points 
where  the  ground  sank  below  their  level,  the  valleys  and 
deeper  depressions  were  usually  boggy,  especially  at  their 
heads. 

The  dip  of  the  plateau  and  the  run  of  the  numerous  ra- 
vines being  toward  the  coast,  the  drainage  of  the  camp  was 
everything  which  could  be  desired.  The  hollow  below  the 
guards'  camp,  the  piece  of  ground  situated  near  the  head- 
quarters of  General  Bosquet,  and  behind  the  sutlers'  village, 
known  in  camp  parlance  as  "Donnybrook,"  and  a  plot  of 
land  under  Cathcart's  hill,  were  the  most  objectionable  parts 
of  the  encampment.  These  spots  were  soon  avoided,  as 
their  pernicious  effect  on  the  health  of  the  troops  sent  to 
occupy  them  was  soon  evident.  Marshy  and  unhealthy 
ground  existed  along  the  Tchernaya,  especially  near  its 
mouth,  and  at  the  head  of  several  of  the  creeks;  but  most 
of  these  points  lay  beyond  the  allied  lines.  The  French 
division,  which  was  at  a  late  period  of  the  war  cantoned 
along  the  river,  suffered  considerably  from  the  marsh  miasma, 
within  the  range  of  whose  influence  they  there  entered. 

The  water  obtained  within  our  lines  was,  on  the  whole, 


*  The  Russians,  Sardinians,  and  Turks  constructed  underground 
huts  for  winter  use;  but  the  difficulty  of  ventilating,  lighting,  and 
keeping  them  dry  more  than  counterbalanced  their  advantages  as  to 
heat.  Malignant  fever  has  been  said  to  increase  much  in  its  viru- 
lence among  troops  so  housed.  How  much  it  may  have  contributed 
to  cause  and  maintain  it  among  the  Russians,  I  am  not  in  a  position 
to  determine. 


32  SURGERY  OF  THE  CRIMEAN  WAR. 

good  in  quality;  but  its  amount  necessitated  economy  in 
its  use  during  summer.  The  fear  that  the  supply  would 
fail  in  autumn  was  one  of  the  many  evil  anticipations  which 
the  establishment  of  the  siege  gave  rise  to  at  home:  but  by 
the  prudent  precautions  adopted  by  the  authorities  in  con- 
structing tanks,  and  placing  the  wells  under  supervision, 
these  anticipations  were  fortunately  not  realized.  Without 
much  attention,  however,  to  the  management  of  the  reser- 
voirs, I  doubt  not  a  scarcity  might  have  been  felt  after  the 
exhausting  drought  of  the  hot  summer  and  the  increasing 
demands  of  an  augmented  army.  During  midsummer  the 
water  obtained  within  the  position  of  the  division  to  which 
I  belonged — the  third — contained  a  vast  number  of  animal- 
culaB,  many  of  them  so  large  as  to  be  seen  by  the  naked  eye 
swimming  about  in  little  shoals  in  the  water  tanks.  How 
far  the  unavoidable  use  of  this  water  may  have  predisposed 
to  that  outbreak  of  cholera  which  took  place  at  that  season, 
it  is  difficult  to  say.  The  wells  were  generally  situated  at 
the  head  of  the  ravines,  down  several  of  which  small  brooks 
flowed  constantly. 

The  pressure  of  other  more  weighty  matters  at  the  early 
part  of  the  siege,  and  the  unanticipated  sojourn  of  the 
troops  on  the  ground,  prevented  that  care  being  at  first 
taken  in  the  arrangement  of  latrines,  slaughter-houses,  etc., 
which  is  so  desirable  in  the  distribution  of  a  camp,  and 
which  was  afterward  so  abundantly  shown.  It  appeared  to 
me  that  the  arrangements  on  this  head  were  better  within 
the  British  than  in  the  French  lines.  The  difficulty  of 
organizing  this  part  of  a  camp  is  by  no  means  trifling,  and 
the  necessity  of  paying  great  attention  to  it  is  evident  when 
troops  remain  long  stationary.*  Pits  were  used  as  latrines 

*  Those  who  visited  the  encampments  of  the  Russians  on  the 
M'Kenzie  plateau  after  peace,  will  easily  be  able  to  understand  what 
a  miserable  condition  cantonments  may  be  reduced  to  by  the  neglect 
of  the  necessary  precautions  on  this  head.  So  to  allocate  sites  for 


FOOD.  33 

by  both  armies,  and  earth  or  lime  was  thrown  on  the  surface 
of  the  ordure.  Generally  speaking,  the  pits  were  too  broad, 
as  they  exposed  too  great  a  surface  to  the  atmosphere.  In 
winter,  the  smell  from  these  pits  was  scarcely  perceived; 
but,  during  the  heats  of  summer,  and  amid  a  teeming  camp, 
it  became  much  more  obvious,  and  must  have  had  a  sensible 
though  little  recognized  effect  on  the  health  of  the  troops, 
more  especially  on  the  progress  of  wounds. 

The  burning  of  the  horse  manure  within  our  lines  was  a 
great  mistake.  The  black  fetid  smoke  hung  in  heavy  folds 
over  the  camp,  and  was  carried  far  and  wide.  The  French 
with  more  wisdom  buried  it.  Such  trivial  circumstances 
assume  an  unlooked-for  magnitude  when  repeated  on  so  vast 
a  scale. 

There  was  yet  another  point  in  the  hygiene  of  the  camp 
which  did  not  at  first  obtain  sufficient  attention.  I  refer  to 
the  burying  of  dead  carcasses.  Many  animals,  horses,  buf- 
faloes, and  bullocks  died  in  passing  to  the  front,  or  after 
arriving  in  camp,  and  from  the  want  of  men  to  bury  them 
were  not  unfrequently  left  to  decay  where  they  fell.  The 
s_te«elrfrom  this  source  between  Balaklava  and  the  head- 
quarters' camp  was  at  one  time  very  offensive,  and  at  last 
compelled  active  interference  for  its  removal. 

During  the  latter  part  of  our  occupation,  the  arrange- 
ments with  regard  to  latrines,  shambles,  the  burying  of  dead 
carcasses,  etc.  were  unexceptionable,  and  every  means  was 
taken  to  abate  their  baneful  influence. 

The  food  provided  for  the  army  during  the  first  winter 
and  spring  was  defective  both  in  quantity  and  quality.  This 
arose  partly  from  unavoidable  circumstances,  and  partly 
from  inexperience  in  the  officers  to  whose  care  was  intrusted 

these  purposes  as  that  they  may  be  accessible  to  the  camp,  and  at 
the  same  time  sufficiently  removed  to  prevent  their  contaminating 
the  air,  aud  that  the  locality  they  occupy  shall  not  be  required  at 
any  future  period  for  the  location  of  troops,  calls  for  considerable 
forethought  and  arrangement. 


34  SURGERY    OF   THE   CRIMEAN    WAR, 

the  supply  of  the  army.  Salt  meat  and  biscuit  constituted 
the  bulk  of  the  distribution,  while  rice,  coffee,  and  sugar 
were  occasionally,  but  sparingly  added.  Sir  Alexander 
Tulloch  says  that,  during  December,  January,  and  February, 
"there  was  almost  a  total  absence  of  fresh  meat,  and  even 
the  sick  were  for  many  days,  nay  even  for  weeks,  fed  exclu- 
sively on  salt  meat,  in  their  state  a  poison."  The  coffee 
being  served  out  raw  and  unground,  was  all  but  useless,  and 
the  ration  salt  pork  was  not  always  of  the  best. 

The  want  of  fuel,  and  the  state  of  fatigue  in  which  the 
men  returned  from  duty,  made  them  frequently  eat  their 
pork  half  dressed,  or  toasted  only  before  their  meager  fires; 
and  this,  together  with  their  ration  of  spirit,  or  it  might  be 
their  biscuits  and  rum  alone,  formed  their  frequent  if  not 
their  only  fare. 

This  circumstance,  taken  into  consideration  along  with 
the  prevalence  of  nlceration  of  the  intestines  which  existed, 
assumes  an  additional  interest  when  connected  with  a  fact 
mentioned  by  Dr.  Rollo,  and  quoted  by  Sir  George  Ballin- 
gall,  that  in  the  year  1789  the  45th  Regiment  lost,  within 
a  short  time,  in  Granada,  and  during  a  healthy  season,  a 
large  number  of  men  who  were  found  to  have  ulcerated  in- 
testines, and,  on  inquiry,  it  was  discovered  that  one  chief 
cause  of  the  mortality  was,  that  the  common  breakfast  con- 
sisted of  a  glass  of  raw  Spirits,  with  a  smjill  slice  of  boiled 
salt  pork,  the  spirits  being  not  unfrequently  repeated  during 
the  day.  May  not  a  like  fare  Have  been  the  cause,  to  some 
extent,  of  a  similar  effect  in  the  Crimea  also? 

I  have  little  doubt,  that  if  the  precaution  had  been  taken 
to  supply  the  troops  every  morning  with  hot  coffee,  as  they 
went  on  or  returned  from  duty,  which  was  a  step  strongly 
recommended  as  a  prophylactic  at  Walcheren,  much  of  our 
mortality  might  have  been  avoided.  It  can  hardly  be 
doubted  that  this  could  have  been  accomplished  at  the  worst 
of  times  by  a  little  management,  as  there  are  few  things 
more  portable  or  more  easily  prepared  than  coffee.  The 


FOOD.  35 

Turks  place  great  reliance  on  this  beverage  as  a  preservative 
against  dysentery,  and  the  French  preferred  its  use  in  their 
army  to  the  tea  which  we  employed.  If  we  were  ordered 
to  prescribe  a  dietary  the  best  adapted  to  give  rise  to  gastric 
irritation  and  dyscrasial  disease,  could  we  suggest  one  more 
potent  than  salt  pork,  hard  biscuit,  and  raw  rum  ? 

Men  severely  worked,  and  constantly  in  a  keen  air,  re- 
quire to  have  their  physical  energies  sustained  by  a  liberal 
supply  of  such  food  as  contains  the  largest  amount  of  nour- 
ishing and  staple  ingredients ;  but  in  place  of  that,  the  sup- 
ply to  our  troops,  besides  being  irregular  in  amount,  was 
insufficient  for  their  support,  and  those  constituents  which 
were  most  calculated  to  provide  for  their  necessities  were 
reduced  at  the  very  time  when  they  were  most  required. 
Thus,  in  November  the  ration  of  biscuit  and  that  of  rice 
were  altogether  stopped,  "so  that  within  one  week  the 
troops  were,  in  most  cases,  deprived  of  nearly  half  a  pound 
of  the  vegetable  and  farinaceous  food  so  much  required  to 
counteract  the  salt  meat  diet,  and  this,  too,  when  scurvy 
had  made  its  appearance."* 

The  want  of  fresh  bread  and  vegetables  was  a  great  and 
serious  privation,  particularly  felt  by  the  sick,  and  those 
whose  gums  were  tender  from  scurvy.  Preserved  vegeta- 
bles, even  when  procurable,  as  they  were  not  till  late  in  the 
war,  are  at  best  but  bad  substitutes  for  fresh  esculents,  and 
lime-juice  did  not  form  part  of  the  distributions  till  the 
scurvy  poison  had  fairly  impregnated  the  systems  of  the 
mcn.f  It  is  useless  now  to  inquire  why  that  store  of  lime- 
juice,  which  is  proved  to  have  lain  at  Balaklava  during  the 
two  months  when  scurvy  most  prevailed,  was  not  distributed 
to  the  longing  troops.  The  fact  can  now  only  be  deplored, 

*  See  Appendix  C. 

f  The  French,  toward  the  end  of  the  war,  established  gardens 
•within  their  position,  particularly  along  the  Tchernaya,  where  they 
cultivated  vegetables.  These  would  have  been  of  the  greatest  im- 
portance it'  the  campaign  had  continued. 


36  SURGERY   OF    THE   CRIMEAN    WAR. 

but  the  fault  seems  to  have  been  one  of  the  commissariat, 
not  of  the  medical  department. 

The  fresh  meat,  which  was  no  less  acceptable  than  rare, 
was  not  by  any  means  invariably  good.  The  miserable  cat- 
tle arrived  in  the  Crimea,  after  the  transit  over  a  stormy 
sea,  in  no  very  favorable  condition  for  the  butcher.  Baudens 
tells  us  the  French  soldiers  characterized  them  as  Pharaoh's 
lean  kine,  and  that  the  use  of  their  flesh  gave  rise  to  intes- 
tinal flux  of  greater  or  less  severity. 

From  a  consideration  of  all  these  circumstances  com- 
bined, in  regard  to  diet  and  cooking,  we  derive  the  expla- 
nation, in  a  great  measure,  of  the  prevalence  of  certain 
diseases  afterward  to  be  specified,  and  the  fatal  virulence  of 
others.* 

The  sick  as  well  as  the  healthy  were  exposed  to  the 
evils  arising  from  the  defective  rationing  winch  I  have  been 
reviewing,  but  the  praiseworthy  and  urgent  efforts  of  the 
medical  officers  were  frequently  rewarded  by  obtaining 
medical  comforts  of  various  descriptions  for  the  hospitals. 
Even  after  they  got  food  for  their  patients,  the  difficulty  of 
preparing  it  suitably  was  a  great  and  trying  one.  It  was 
one,  however,  which  their  humanity  and  energy  surmounted 
to  a  considerable  extent. 

In  all  these  remarks,  I  beg  to  repeat  that  I  allude  only 
to  the  early  period  of  the  war,  as,  latterly,  every  luxury 
prevailed  in  our  hospitals,  and  our  army  lived  as  I  suppose 
no  army  has  ever  before  fared  in  the  annals  of  warfare.  The 

*  It  is  much  to  be  regretted  that  the  difficulties  of  transport  make 
it  almost  impossible  to  vary  the  food  of  the  soldier  in  the  field.  The 
constant  repetition  of  the  same  rations,  the  absolute  uniformity  in 
every  item  of  food,  is  but  too  apt  to  occasion  aversion,  especially 
with  those  in  whom  disease  is  beginning  to  show  itself.  I  can  speak 
from  personal  experience  as  to  the  strong  predisposition  of  this  one 
cause  in  giving  rise  to  the  fever  designated  "  Crimean,"  and  I  know 
of  few  things  which  had  a  more  undoubted  effect  on  the  health  of 
the  troops. 


FUEL — CLOTHING.  3Y 

change  which  took  place  in  this  respect  has  occasioned  the 
handsome  compliment  from  the  French  medical  inspector, 
in  his  review  of  the  campaign:  "Quand  on  compare  les 
conditions  ou  se  trouverent  les  Anglais  au  debut  de  la 
guerre  qui  les  prenait  au  depourvu  et  celles  ou  ils  s'etaitent 
places  en  1856  on  est  force  de  reconnaitre  la  grandeur  de  la 
nation  Britannique." 

For  fuel  the  army  was  chiefly  dependent,  early  in  the 
siege,  on  the  underwood  which  covered  part  of  the  plateau, 
and  afterward  on  the  roots  of  these  bushes.  They  had  to 
dig  for  this  "  underground  forest "  often  beneath  snow, 
always  among  wet  mud,  after  the  more  fatiguing  duties  of 
the  day  were  over,  and  so  it  was  that  much  time  was  thus 
lost  before  they  could  procure,  and  still  more  before  they 
could  ignite,  these  wet  roots,  which  were  their  only  resource. 
A  cheerful  fire  came  to  be  almost  unknown ;  and  I  have 
heard  many  of  the  survivors  say  that  few  objects  appeared 
so  frequently  to  tantalize  them  in  their  dreams.  It  was 
always  difficult  to  obtain  even  as  much  firing  as  served  the 
bare  necessities  of  the  camp.  This  deficiency  was  severely 
felt  during  the  inclemency  of  winter,  and  enhanced  greatly 
the  other  hardships;  for  it  is  a  very  true  remark,  that  "a 
sufficient  supply  of  firewood  during  a  campaign  is  one-half 
of  a  soldier's  existence." 

The  deficiency  of  clothing,  which  was  so  much  complained 
of  during  the  early  part  of  the  war,  was  one  of  the  most 
prolific  sources  of  subsequent  disease  among  the  troops. 
The  soldiers'  kits  having  been  left  on  board  ship  when  the 
landing  was  effected  at  Old  Fort,  and  not  being  delivered  to 
them  till  long  afterward,  compelled  the  men  to  perform  much 
of  the  trench  work  in  tatters  during  the  severity  of  a  Crimean 
winter.  Their  shoes,  originally  bad,  were  in  many  cases 
totally  destroyed  before  they  had  been  long  used,  and  their 
only  suit  of  clothes  was  soon  reduced  to  shreds.  The 
(.Quartermaster-General  tells  us  that  "  they  had  had  the  suit 
they  wore  in  the  voyage  out  to  the  Mediterranean,  through 

4 


38  SURGERY    OF    THE   CRIMEAN    WAR. 

the  service  in  Bulgaria,  through  the  sea-voyage  to  the  Crimea ; 
they  had  worked  in  these  coats  in  the  trenches,  and  fought 
all  through  with  them ;  they  were  perfectly  threadbare,  and 
in  many  instances  did  not  exist."  All  this,  too,  was  allowed 
to  take  place,  and  the  men  to  be  exposed  to  the  wet  of  winter, 
and  severe  cold  in  the  trenches,  while  "thousands  of  coats 
we're  lying  unused,  and  tens  of  thousands  of  greatcoats, 
blankets,  and  rugs  filled  the  Quartermaster- General's  stores, 
or  the  harbor  of  Balaklava."* 

The  one  only  blanket  which  each  soldier  possessed  afforded, 
even  when  dry,  but  a  feeble  protection  against  the  cold  of 
the  tents,  but  as  he  generally  carried  the  same  blanket  with 
him  into  the  trenches,  it  was  commonly  dirty  and  soaked 
with  water  when  he  came  to  sleep  in  it  at  night.  The  sole- 
less  boots  were  seldom  removed  when  he  lay  down  to  sleep, 
so  firmly  adherent  were  they  to  the  swollen  feet.  Such  was 
the  condition  of 

"The  poor  soldier  that  so  richly  fought, 
Whose  rags  sham'd  gilded  arms." 

The  uniform  which,  of  all  others,  seemed  best  adapted  for 
the  Crimea,  was  that  worn  by  our  enemies.  The  long,  warm 
gray  coat,  gathered  in  folds  over  the  loins,  the  low,  flat  cap, 
and  the  wide  half  boot,  within  which  the  trowsers  were 
tucked,  formed  a  much  better  provision  against  the  cold  winds 
of  winter  and  the  deep  tenacious  mud,  than  the  dress  worn 
by  any  portion  of  the  allied  army.  The  coats  of  the  Sar- 
dinians approached  nearest  in  shape  to  those  of  the  Russians, 
and  the  French  gaiters,  though  most  serviceable,  were  not 
equal  to  the  half  boots  of  their  enemies. 

The  housing  of  the  troops  during  the  early  part  of  the 
war  was  in  keeping  with  their  food  and  clothing.  At  first 

*  The  loss  of  the  Prince  was  one  great  cause  of  the  deficiency  of 
•warm  clothing.  In  her  went  down  53,000  woolen  shirts,  17,000 
drawers,  16,000  blankets,  2500  watch-coats,  25,700  socks,  3700 
rugs. 


HOUSING.  39 

the  common  bell  tent  was  used  ;  huts  were  afterward  added. 
This  tent  measures  13  feet  8  inches  in  diameter  and  10  feet 
in  height.  It  contains  about  512  cubic  feet  of  air,  has 
almost  no  means  of  ventilation  when  closed,  and  was  yet 
made  to  accommodate  fifteen  men,  who  lay  at  night  without 
bedding  on  the  bare  ground.  It  may  be  easily  imagined 
how  vitiated  the  atmosphere  of  these  tents  was  in  the  morn- 
ing, when  they  had  been  kept  close  all  night  by  their  inmates 
in  order  to  make  themselves  warm. 

In  pitching  the  tents,  far  too  little  space  was,  at  first,  left 
between  them.  In  many  camps,  the  ropes,  instead  of  being 
stretched  to  their  full  length,  were  greatly  shortened,  which, 
while  it  unduly  crowded  the  tents,  necessarily  lessened  their 
stability.  This  arrangement  was  most  injudicious,  and  did 
much,  I  doubt  not,  to  render  the  camp  more  injurious  to 
health  than  it  would  otherwise  have  been. 

The  earth  upon  which  tents  are  pitched  undoubtedly  ab- 
sorbs much  animal  effluvia,  and  comes'to  give  out  unhealthy 
emanations,  which  remain  in  the  upper  part  of  a  tent,  and 
can  be  got  quit  of  only  by  striking  it  altogether,  or  removing 
it  to  another  spot. 

The  huts  at  first  used  for  barracks  were  that  known  as  the 
"Portsmouth  hut,"  which  measured  27  x  15  feet  inside,  6  feet 
to  the  eaves,  and  12  to  the  ridge.  Each  contained  about 
3645  cubic  feet  of  air,  and,  when  occupied  by  twenty-five 
men,  allowed  about  146  cubic  feet  to  each.  The  Chester 
huts,  which  came  to  camp  at  a  later  period,  were  larger  and 
better  constructed  than  the  Portsmouth.  The  errors,  how- 
ever, of  all  the  huts  were  the  want  of  sufficient  independent 
means  of  ventilation,  and  the  mode  in  which  they  were  usu- 
ally erected.  Sufficient  care  was  not  always  taken  to  prepare 
the  ground  by  draining  and  covering  it  with  loose  rubble,  - 
before  laying  the  flooring.  Their  walls,  too,  except  in  the 
case  of  the  paneled  huts,  were  too  thin. 

The  duty  which  fell  to  be  performed  by  the  army  was  ex- 
tremely heavy  during  the  whole  period  of  the  siege,  and  es- 


40          SURGERY  OP  THE  CRIMEAN  WAR. 

pecially  during  the  first  winter,  when  the  amount  of  trench 
to  be  constructed  was  very  great,  and  when,  from  the  number 
of  sick,  a  double  share  of  duty  fell  on  the  effective. 

It  is  well  known  that  the  extent  of  "approach  "at  first 
assigned  to  the  British  army  was  very  disproportionate  to 
its  relative  numbers  as  compared  with  the  French,  The 
whole  right  attack  of  the  combined  army  was  appropriated 
to  our  forces,  and  thus  they  had  to  form  those  vast  trenches 
(the  more  extensive  as  they  were  distant  from  the  enemy's 
works)  which  were  afterward  consigned  to  our  gallant  allies, 
and  made  the  basis  of  the  triumphant  advance  against  the 
key  of  the  position — the  Mamelon  vert  and  the  Malakoff. 

But  trench  work  did  not  comprise  the  whole  duty,  as,  when 
not  so  engaged,  the  carrying  of  water  and  the  procuring  of 
fuel  engrossed  the  few  remaining  hours,  so  that  the  leisure 
enjoyed  was  but  scant,  and  the  opportunities  few,  for  con- 
structing any  means  of  protection  against  the  cold.  During 
December,  January,  and  February,  1855-56,  the  term  of 
duty  in  the  trenches  was  so  frequent  that  it  required  super- 
human exertion.  Thus,  by  the  returns,  it  is  shown  that  out 
of  an  effective  strength  of  11,367  in  January,  5321  were 
told  off  daily  for  duty.  The  routine  of  this  duty  is  well 
illustrated  by  the  extracts  given  in  the  appendix  (D)  from 
Sir  Alexander  Tulloch's  pamphlet ;  and  if  for  a  moment  it 
is  realized — if  we  consider  that  this  dreadful  ordeal  had  to  be 
undergone  day  after  day,  and  week  after  week,  without  any 
intermission  but  that  brought  by  the  invasion  of  heavy  sick- 
ness or  the  hand  of  death,  then  may  we  perhaps  estimate  the 
effect  of  such  duty  on  the  health  and  constitution  of  those 
who  survived.  The  very  fact  that,  during  peace,  our  soldiers, 
either  at  home  or  in  the  garrison  towns  abroad,  live  a  life  of 
ease  and  plenty,  made  such  unaccustomed  duties  peculiarly 
severe,  and  the  effect  the  more  certainly  destructive.  But  it 
would  only  suggest  half  the  truth  were  we  to  suppose  that 
in  the  phrase  "  trench  duty,"  the  hard,  bodily  exertion  of  dig- 
ging was  alone  included.  It  was  the  standing  ankle  deep  in 


DUTY.  41 

mud,  or  snow,  or  frozen  water  while  they  worked;  the  want 
of  shelter,  and  the  absence  of  a  dry  resting-place  when  ex- 
hausted; the  mental  depression  produced  by  such  spade  and 
pickaxe  work ;  the  danger  which  accompanied  it  from  sudden 
sortie,  bounding  round  shot,  and  exploding  shell;  thejtotal 
absence  of  all  comfort  on  returning  to  camp,  and  the  cease- 
less recurrence,  without  apparent  results,  of  the  same  routine, 
which  rendered  this  "trench  work"  so  truly  what  the  soldiers 
called  it,  "desperate."  The  evidence  of  the  mental  depres- 
sion to  which  I  refer  will  present  itself  in  dread  remembrance 
to  those  who  can  recall  the  condition  of  the  soldiers  during 
the  first  five  months  of  the  siege;  and  its  influence  on  the 
outbreak  and  fatality  of  disease,  as  well  as  on  convalescence, 
cannot,  I  believe,  be  exaggerated. 

From  all  that  has  been  said,  then,  on  the  housing,  clothing, 
food,  and  fuel  provided  for  the  soldiers,  and  the  killing  toil 
exacted  from  them  during  that  period  of  the  war  which  had 
most  influence  on  their  health  and  after-history,  the  sad  pic- 
ture may  be  formed  of  their  position  in  the  Crimea.  Day 
after  day  passed  in  severe  bodily  exertion  and  anxious 
watching — one  moment  digging  laboriously  in  extending  the 
approaches,  and  the  next  with  arms  in  hand  repelling  the  as- 
saulting enemy;  almost  always  wetj  exposed  without  cover 
to  the  drenching  rain  and  soaking  snow,  the  keen  frost  and 
biting  wind ;  standing  for  days  in  wet  mud ;  constantly  either 
unnaturally  excited  or  depressed;  ever  in  danger  and  with- 
out hope  of  a  change;  their  dirty,  humid  clothes  in  rags, 
their  bodies  covered  with  loathsome  vermin  which  seemed  to 
grow  out  of  their  very  flesh ;  no  comforts  in  their  wind- 
pierced  tents  on  the  bleak  plateau ;  no  fires,  unless,  weary 
and  foot-sore  as  they  were,  they  dug  beneath  the  snow- 
covered  sod  for  wet  roots  wherewith  to  kindle  a  feeble  and 
tantalizing  blaze;  without  food  till,  after  hours  of  perse- 
vering exertion,  they  managed  to  half  cook  their  unpalatable 
ration  over  their  winking  fire ;  huddled  into  a  crowded  tent 
to  pass  the  night  in  a  close,  noisome  atmosphere,  on  the  oozy 

4* 


42  SURGERY    OP    THE    CRIMEAN    WAR. 

ground,  covered  by  the  same  blanket  which  protected  them 
in  the  wet  and  muddy  trenches;  longing  for  the  morning, 
though  its  early  dawn  was  signaled  by  the  bugle  sound  which 
called  them  to  a  renewal  of  that  dread  task  whose  severity 
made  them  yet  again  sigh,  "would  to  God  it  were  night." 
This  sketch  is  no  exaggeration.  It  is  true,  though  diffi- 
cult to  be  realized  even  now  by  those  who  themselves  saw  it. 

Can  we,  then,  find  anywhere  else  in  reality — nay,  can  we, 
by  the  utmost  stretch  of  imagination,  conceive  a  more  fruitful 
field  for  the  seeds  of  disease,  or  the  harvest  of  death,  than  is 
here  presented  to  us  in  the  camp  of  the  weary,  anxious- 
minded  soldiers  who  fought  so  gallantly,  endured  so  con- 
stantly, or  died  so  nobly,  and  who  now  consecrate,  by  their 
humble  graves,  the  green  hillsides  and  lonely  valleys  of  the 
Crimea  ? 

The  bare  remembrance  of  that  frightful  combination  of 
circumstances  which  seemed  to  encircle  our  army  as  with 
ever-contracting  walls  of  iron,  and  make  it  prisoners  for 
those  dread  scourges,  cholera,  fever,  and  dysentery,  that, 
like  the  angel  of  death  in  the  camp  of  Sennacherib,  de- 
stroyed our  noble  and  gallant  army,  comes  to  one's  memory 
like  the  awful  vision  of  a  distempered  dream. 

These  things  must  be  here  recalled  as  they  had  a  most 
important  influence  on  the  annals  of  the  war,  and  much  that 
would  otherwise  be  unintelligible  becomes  clear  as  noonday 
when  read  by  the  light  thrown  on  it  by  these  circum- 
stances.* 

*  "The  poor  condemned  English, 
Like  sacrifices,  by  their  watchful  fires 
Sit  patiently,  and  inly  ruminate 
The  morning's  danger;  and  their  gesture  sad, 
Investing  lank-lean  cheeks,  and  war-worn  coats, 
Presented  them  unto  the  gazing  moon 
So  many  horrid  ghosts." — KING  HENRY  V.,  act.  iv.  scene  1. 

How  completely  does  the  noble  heroism  displayed  by  our  troops 
in  the  Crimea  refute  General  Foy's  estimate  of  them!  "The  Eng- 


HOSPITALS.  43 

But  if  such  a  condition  of  things  as  I  have  feebly  out- 
lined was  trying  to  the  strong,  how  can  I  express  its  influ- 
ence on  the  weak !  It  is  impossible  fully  to  realize  the 
hopeless  condition  of  the  sufferers,  struck  down  by  enfee- 
bling sickness  or  exhausting  wounds,  and  deprived  of  that 
vigor  which  alone  made  hardship  endurable. 

The  regimental  hospital  marquee  and  the  round  bell  tent 
which  served  as  hospitals  were  of  necessity  vastly  over- 
crowded.* The  former,  which  measures  27  X  14  feet  in- 
side, and  affords  about  3250  cubic  feet  of  air,  ought  to  have 
contained  only  twelve  to  fifteen  men,  but  was  made,  from  the 
exigency  of  the  service,  to  cover  three  times  that  number. 
The  unsuitableness  of  the  bell  tent  to  hospital  purposes  has 
been  fully  expressed  by  the  commissioners  when  they  say : 
"Whatever  may  be  the  supposed  advantages  which  have  led 
to  its  adoption  as  a  barrack  tent,  it  would  be  difficult  to 
contrive  anything  much  more  unfit  for  the  accommodation 
of  the  sick."  There  were  no  bedsteads,  and  those  patients 
who  had  empty  sacks  to  lie  upon  were  considered  fortunate. 
Few  blankets  belonged  to  the  hospitals,  and  the  food  which 

lish  soldier,"  he  says,  "is  not  brave  at  times  merely;  he  is  so  when- 
ever he  has  eaten  well,  drunk  well,  and  slept  well.  Yet  their  courage 
— rather  instinctive  than  acquired — has  need  of  solid  nutriment; 
and  no  thoughts  of  glory  will  ever  make  them  forget  that  they  are 
hungry,  or  that  their  shoes  are  worn  out." — For,  vol.  i.  p.  231. 

*  If  properly  constructed  and  erected  on  suitable  ground,  there 
are  no  structures  better  adapted  for  the  hospitals  of  an  army  in  the 
field  than  wooden  huts  or  canvas  tents.  The  dreadful  epidemics 
which  have  so  frequently  pursued  armies,  and  the  mortality  which 
has  attended  their  wounds,  have  in  not  a  few  instances  been  due  to 
the  employment  of  stone  buildings  as  hospitals.  The  ventilation  is 
more  apt  to  be  deficient  or  to  become  deranged  in  them  than  in  huts 
or  tents,  and  hence  the  effects  of  overcrowding  become  the  more 
pernicious.  "  It  was  often  proved  in  the  history  of  the  late  war," 
says  Jackson  in  his  work  on  the  economy  of  armies,  "that  more 
human  life  was  destroyed  by  accumulating  sick  in  low  and  ill-venti- 
lated apartments,  than  in  leaving  them  exposed  in  severe  and  in- 
clement weather  at  the  side  of  a  hedge  or  common  dike." 


44  SURGERY  OP  THE  CRIMEAN  WAR. 

they  afforded  was  but  ill  adapted  for  sick  men — nay,  in 
many  instances,  constituted  a  veritable  poison ;  medicines, 
even  the  most  necessary,  but  scantily  provided;  attendance 
by  overworked,  and  in  many  cases  sick  doctors,  and  by  a 
handful  of  orderlies,  themselves  for  the  most  part. convales- 
cents, whose  natures,  however  kind  originally,  must  have 
become  soured  and  crabbed  by  the  hardships  and  fatigue  to 
which  they  were  exposed — such  was  the  condition  of  the 
sick  during  the  first  winter.  If  to  sickness  were  added 
wounds — a  broken  limb  or  contused  body — how  small  was 
the  chance  of  recovery!  Splints  and  bandages  merely 
teazed  and  fretted.  The  man  lost  hope.  Every  circum- 
stance forbade  recovery.  The  powers  of  evil  seemed  to 
grasp  his  destiny.  The  problem  of  life  was  being  solved, 
by  every  conceivable  antagonism  having  a  voice  in  the 
momentous  decision.  Such  being  the  circumstances  given, 
how  could  any  other  result  follow  than  a  mortality  which 
caused  our  land  to  ring  with  the  voice  of  mourning,  and 
which  for  a  moment  paralyzed  our  senate  and  our  people? 
The  wildness  of  despair  is  the  only  excuse  which  can  be 
made  for  the  blame  of  so  much  misery  having  been  cast  on 
the  medical  department,  which  had  no  control  whatever 
over  the  events  that  led  to  it,  and  the  voluntary  sacrifice  of 
whose  members,  though  glorious  to  themselves,  was  unable 
to  retrieve  the  deplorable  errors  committed  by  others. 

During  the  early  part  of  the  war,  the  regimental  hospital 
system,  which  I  believe  is  peculiar  to  the  British  army,  was 
alone  followed  *  At  a  later  period,  general  hospitals  were 

*  According  to  this  plan,  the  soldiers  are  kept,  when  sick,  in  hos- 
pitals which  belong  to  their  regiments,  in  place  of  being  transferred 
to  general  hospitals  established  to  receive  the  common  sick  of  the 
army.  The  discussion  is  an  old  one  as  to  whether  the  system  which 
has  been  always  followed  by  us,  except  in  times  of  great  necessity, 
or  that  of  general  hospitals,  the  plan  adopted  by  the  French  and 
other  continental  nations  during  war,  is  the  best.  I  do  not  intend 
here  to  review  the  question,  but  would  merely  remark  that,  after 


HOSPITALS.  45 

established.  One  large  building  at  Balaklava,  which  had 
been  a  military  school,  was  early  appropriated  to  this  pur- 

fairly  weighing  the  subject,  I  think  the  regimental  hospital  arrange- 
ment presents  the  greatest  advantages.  One  strong  claim  which  it 
has  on  our  support  is,  that  the  surgeon  of  the  corps  must  be  greatly 
better  acquainted  with  his  men,  their  character  and  habits,  and  thus 
be  more  able  to  treat  them,  as  well  as  more  able  to  detect  imposture 
if  attempted,  than  the  medical  attendant  who  probably  never  saw 
them  till  they  present  themselves  to  him  as  patients.  The  men  are 
by  this  system  also  kept  among  their  comrades — no  small  advantage 
to  them — and  thus  their  minds  are  cheered  by  the  companionship  of 
friends.  More  time  and  attendance,  too,  can  be  bestowed  on  the 
sick  in  these  small  hospitals,  from  the  proportion  of  medical  attend- 
ants and  orderlies  being  in  general  much  above  what  it  is  in  the 
larger  establishments,  and  from  the  responsibility  being,  if  possi- 
ble, more  binding  on  the  regimental  surgeon,  and  the  stock  of  com- 
forts proportionally  greater  and  more  regularly  supplied,  from  the 
resources  of  the  whole  regiment  being  at  his  command.  In  regi- 
mental hospitals  it  is  well  known  that  wounds  heal  more  satisfac- 
torily, and  that  purulent  infection  and  gangrene  occur  more  rarely, 
most  probably  because,  from  the  mixture  of  cases  which  takes  place 
in  them,  that  segregation  of  suppurating  wounds  which  is  so  apt  to 
occur  in  general  hospitals  is  avoided. 

On  the  other  hand,  a  much  larger  staff  is  required  when  the  hos- 
pitals are  confined  to  regiments.  A  regiment  numbering  one  thou- 
sand men  on  active  service  has  a  surgeon  and  three  assistants  at- 
tached to  it,  all  of  whom  are  rendered  useless  if  their  corps  is  not 
engaged,  while  a  superabundance  of  work  falls  to  the  lot  of  those 
medical  officers  whose  regiments  have  suffered  severely  in  action. 
Hence  it  follows,  that  if  the  whole  medical  staff  of  the  army  Avas 
united  and  concentrated  in  general  hospitals,  less  than  one-half  of 
the  aggregate  number  of  professional  men  would  suffice  for  the  serv- 
ice. In  the  French  army,  the  proportion  of  medical  officers  to  the 
strength  is  not  a  third  so  large  as  in  ours. 

Besides,  a  more  uniform  system  can  be  followed  in  the  treatment 
of  the  cases,  and  the  results  of  such  treatment  made  more  available 
both  for  instructing  the  younger  surgeons,  and  also  for  the  promo- 
tion of  science,  when  conducted  in  large  hospitals,  than  it  can  ever 
be  in  small  detached  establishments.  The  cost  of  administration 
also  will  be  greatly  diminished  by  concentration,  and  the  whole 


4G  SURGERY    OP   THE    CRIMEAN    WAR. 

pose ;  and,  as  the  number  of  sick  increased,  huts  were 
erected  to  add  to  its  accommodation.  This  hospital  was 
chiefly  used  as  a  depot  for  the  sick  about  to  embark  for  the 
Bpsphorus,  and  for  the  treatment  of  sailors  and  native  - 
laborers.  The  position  of  the  hospital  was  most  unfor- 
tunate. In  summer,  it  was  a  perfect  furnace,  "perched  as 
it  was  in  the  focus  of  a  concave  mirror,  of  which  the  sides 
were  formed  of  bare  rock,  and  the  bottom  by  the  smooth 
water  of  the  harbor;"  and  its  near  neighborhood  to  the 
town  was  a  great  disadvantage. 

Above  Balaklava,  on  the  face  of  the  precipitous  rocks  of 
the  coast,  a  number  of  Portsmouth  and  double-walled  huts 
formed  the  sanitarium,  to  which  convalescents  were  sent 
from  camp.  The  exposed  position  of  this  hospital  made  it 

economy  of  the  army,  as  regards  the  management  and  transport  of 
the  sick,  easier  arranged  and  much  more  efficiently  conducted.  But 
with  all  this — and  it  is  a  very  great  deal — to  be  said  in  favor  of  large 
hospitals,  yet  I  unhesitatingly  think  that,  tried  by  the  one  great  test 
of  the  saving  and  prolongation  of  life,  which  in  our  army  at  least 
is  the  chief  criterion  of  advantage,  the  regimental  hospital  system 
is  the  best.  If  this  system  had  existed  in  the  French  army,  they 
never  could  have  carried  on  their  medical  service,  from  the  weakness 
of  their  staff.  If  our  surgeons  were  overworked,  what  must  be  said 
of  the  French,  who,  with  a  much  larger  proportion  of  sick,  had  only 
one  medical  officer  in  proportion  to  three  of  ours!  Thus,  at  Con- 
stantinople during  the  winter  of  1854-55,  a  French  surgeon  told  me 
he  had  211  patients  to  see  before  9  A.M.,  when,  by  their  regulations, 
the  visit  must  be  terminated.*  With  us,  too,  the  continuance  of  the 
war  not  only  decreased  the  sick  list,  but  augmented  the  medical 
staff,  so  that  at  its  termination,  what  between  civil  surgeons,  assist- 
ant surgeons,  acting  assistant  surgeons,  and  dressers,  our  hospitals, 
.especially  those  in  the  rear,  were  inundated  by  professionals  of  every 
type,  while  the  few  who  joined  the  army  of  our  allies  barely  made 
up  for  the  vast  mortality  which  their  constant  labor  and  exposure 
to  disease  occasioned. 


*  The  French  were  so  ill  off  for  medical  attendants  that  they  had  to  employ  intel- 
ligent soldiers  to  dress  not  only  simple  wounds,  but  often  stumps  also,  (under  super- 
intendence.) This  most  useful  corps  was  called  "Soldats  panseurs." 


HOSPITALS.  47 

by  no  means  an  agreeable  winter's  residence;  but  in  sum- 
mer, its  airy  position  and  the  glorious  view  it  commanded 
afforded  a  most  agreeable  and  beautiful  residence  for  the 
sick  who  were  oppressed  by  fever  and  lingering  convales- 
cence on  the  burning  and  arid  plateau.  This  hospital  con- 
tained between  400  and  500  beds;  and  the  results  obtained 
in  it  were  unequaled,  in  so  far  as  curing  disease  was  con- 
cerned. 

Another  sanitarium  was  formed  above  the  monastery 
of  St.  George,  at  an  elevation  of  500  feet  above  the  sea, 
and  consisted  of  twelve  large  Chester  double  huts,  each 
fitted  up  for  twenty  beds.  The  accommodation,  both  in 
the  number  of  huts  and  in  the  number  of  beds  which  each 
could  be  made  to  afford,  could  be  greatly  multiplied  on  an 
emergency.  The  construction  of  the  huts  which  formed 
this  hospital  was  perfect,  the  ventilation  everything  which 
was  desirable,  the  water  supply  sufficient,  the  kitchen 
arrangements  most  excellent ;  and,  altogether,  this  estab- 
lishment might  have  proved,  if  erected  at  an  earlier  period, 
one  of  the  most  useful,  as  it  was  one  of  the  most  perfect 
hospitals  in  the  East.  The  beautiful  scenery  by  which  it 
was  surrounded,  the  cool  breezes  which  fanned  it  even  in 
the  heart  of  summer,  the  agreeable  walks  around,  and  the 
distance  it  was  from  the  turmoil  of  the  camp,  combined  to 
render  "the  monastery"  as  pleasing  a  residence  as  it  was  a 
favorable  station  for  the  sick. 

The  general  hospital  in  camp,  which  might  have  been 
termed  "the  acute  hospital,"  as  to  it  the  men  struck  down 
in  the  trenches  were  first  carried,  was  well  situated  on 
ground  elevated  between  400  and  500  feet  above  the  sea 
level,  within  the  lines  of  the  3d  Division,  and  close  to  the 
extreme  left  of  our  position.  It  consisted  at  first  of  twenty, 
and  latterly  of  thirty  Portsmouth  huts.  These  huts  were 
erected  in  four  rows,  facing  west,  leaving  three  broad  streets 
between  them.  A  space  of  about  twelve  to  fifteen  feet  in- 
tervened between  neighboring  huts.  This  close  packing 


48  SURGERY   OP    THE   CRIMEAN    WAR. 

was  much  to  be  regretted  in  the  arrangement  of  the  huts; 
but  as  they  had  originally  been  erected  for  the  accommoda- 
tion of  the  14th  and  39th  Regiments,  and  as  space  was  not 
easily  procurable  where  so  large  an  army  had  to  be  en- 
camped, the  error  was  in  a  great  measure  unavoidable. 
The  ground  on  which  these  huts  were  erected  had  not  been 
at  first  as  carefully  prepared  or  drained  as  it  would  have 
been  if  they  had  been  originally  erected  for  hospitals. 
Along  the  sides  of  each  intervening  street,  deep  ditches 
were  dug,  after  its  conversion  into  a  hospital,  to  secure 
the  drainage,  and  latterly  the  streets  themselves  were  paved 
with  round  stones.  A  corps  of  Tartars  was  constantly 
employed  in  keeping  the  ground  clean  about  the  huts.  The 
cookhouse  and  latrines  were  placed  behind — the  latter  on 
the  declivity  of  the  hill  leading  down  into  the  valley  which 
bounded  our  camp  from  the  higher  plateau.  These  huts 
were  erected  during  the  winter  of  1854-55,  but  they  were 
not  used  for  hospital  purposes  till  late  in  the  spring  of  the 
latter  year.  They  were  barely  out  of  range,  as  some  of  the 
long  shots  from  the  well-known  "crow's  nest"  battery  came 
at  times  disagreeably  near;  but  this  propinquity  favored 
the  rapid  admission  of  the  wounded  from  the  siege  works. 
Each  hut  measured  twenty-seven  feet  by  fifteen  inside,  and 
contained,  during  the  siege,  fourteen  beds;  but,  when  the 
town  fell,  the  number  of  beds  was  reduced  to  twelve.  The 
air  contained  in  these  huts  allowed  about  260  cubic  feet  to 
each  of  fourteen  patients.  The  total  accommodation  afforded 
by  this  hospital,  during  the  siege,  was  420  beds.  The  ar- 
rangement of  the  huts  was  as  follows :  At  one  end  the  door 
opened  without  the  protection  of  a  porch,  (a  grave  fault;)  at 
the  end  opposite  to  the  door  was  a  window ;  and,  in  some 
cases,  there  were  also  windows  in  the  side  walls,  and  a  fixed 
one  above  the  door.  The  beds  were  placed  on  either  side, 
the  heads  being  close  to  the  wall,  and  the  feet  toward  the 
center  passage,  which  was  three  feet  broad ;  one  foot  and  a 
half  of  open  space  was  left  between  the  beds.  There  was 


HOSPITALS.  49 

a  stove  in  the  center,  and  ventilation-traps  were  cut  in  the 
sides,  and  in  many  cases  in  the  roof.  The  openings  in  the 
sides  could  be  closed  at  night,  or  in  stormy  weather.  These 
huts  being  constructed  of  single  boards,  and  roofed  with 
felt,  were  not  impervious  either  to  rain  or  cold.  In  wet 
weather,  water  decks  had  to  be  constructed  of  waterproof 
sheeting.  Many  of  them  were  completely  floored  with 
planks ;  but  some  had  merely  a  raised  dais  on  either  side 
for  the  beds.  Peat-charcoal  or  lime  was  frequently  strewn 
beneath  the  planking,  and  the  most  scrupulous  cleanliness 
was  rigidly  enforced.  The  men's  kits  were  stowed  in  huts 
set  apart  for  the  purpose,  so  as  to  relieve  the  wards  as  much 
us  possible  from  incumbrance.  The  bedsteads  and  bedding 
were  excellent,  the  provision  of  medical  comforts  good,  and 
the  cooking  passable;  so  that,  on  the  whole,  a  better  field 
hospital  in  the  camp  of  an  active  army,  I  suppose  never 
existed. 

To  a  hospital  so  situated,  one  whose  object  was  so  tempo- 
rary, and  whose  inmates  were  so  liable  to  fluctuation,  we 
cannot  apply  the  same  rules  of  criticism  that  we  adopt  when 
discussing  the  merits  of  more  permanent  establishments. 
That  the  patients  were  often  crowded,  that  the  proper 
amount  of  air  was  not  measured  out  to  each,  that  many  of 
the  refinements  of  a  London  hospital  were  wanting,  may  be 
admitted ;  but  I  doubt  whether  a  better  hospital  could  be 
provided  3000  miles  from  England,  in  a  crowded  camp,  in  a 
houseless  region,  before  an  active  and  energetic  enemy,  and 
almost  within  the  vortex  of  the  strife.  The  ventilation  was 
much  better,  even  at  the  times  of  greatest  crowding,  than 
could  be  supposed  possible ;  and,  as  the  wards  were  seldom 
full,  except  for  short  periods  after  some  of  the  great  battles 
or  assaults,  it  was  generally  beyond  cavil.  Unquestionably 
the  beds  were  too  close;  the  huts  were  too  near  one  another, 
and  erected  within  the  precincts  of  a  crowded  camp ;  and,  in 
summer,  the  heat  was  great ;  but  while  I  most  willingly  allow 

5 


50  SURGERY    OF    THE    CRIMEAN    WAR. 

that  there  was  much  in  all  this  which  was  reprehensible,  still 
I  cannot  conscientiously  say  that  I  had  often  reason  to  com- 
plain of  the  close  air  of  the  wards.  The  thinness  of  the 
walls  of  the  huts,  and  the  numerous  air-traps  cut  in  them, 
did  much  to  prevent  the  formation  of  a  dangerous  atmo- 
sphere, but  gave  rise  to  disagreeable  currents  of  air,  of  which 
the  men  often  complained.  This  could  not  be  effectively 
overcome  by  any  lining,  short  of  wood.  The  absence  of 
porches  to  the  doors  greatly  favored  these  draughts.  In 
winter,  the  huts  were  very  cold  and  uncomfortable,  notwith- 
standing the  pains  we  took  to  hang  up  blankets  and  bed- 
covers round  the  beds. 

The  routine  followed  in  the  distribution  of  the  patients 
was  as  follows:  The  regimental  hospitals  received  all  those 
men  of  their  respective  corps  who  fell  sick,  and  the  wounded 
were  also  admitted  into  these  erections  during  the  early 
months  of  the  siege,  before  the  establishment  of  the  general 
hospitals.  Latterly,  however,  the  large  accommodation  af- 
forded by  the  general  hospital,  and  its  near  neighborhood  to 
the  works,  caused  most  of  the  severely  wounded  to  be  sent 
there,  in  place  of  being  sent  to  their  regiments.  This  remark 
does  not  apply  to  the  light  division,  or  the  more  distant  parts 
of  the  right  attack,  except  after  the  great  explosion  within 
their  lines  in  November,  1856,  when,  from  the  destruction  of 
the  regimental  hospitals,  a  large  number  of  the  injured  were 
admitted  into  the  camp  hospital.* 

During  the  ordinary  course  of  the  siege,  assistant-surgeons, 
stationed  with  the  troops  in  the  works,  paid  the  first  atten- 
tion to  the  wounded,  before  they  were  sent  to  the  rear;  but 
at  the  time  of  any  assault,  a  staff-surgeon,  in  addition  to 
assistants,  was  advanced  into  one  of  the  ravines,  and  per- 


*  I  have  not  spoken  of  the  naval  hospital,  because  it  was  not  a 
military  establishment;  but,  both  in  construction  and  management, 
it  was  one  of  the  most  perfect  hospitals  possible. 


HOSPITALS.  51 

formed  many  necessary  operations  besides  attending  to  the 
transmission  of  the  wounded.* 

For  many  months  before  the  termination  of  the  siege,  the 
wounded  were,  with  very  few  exceptions,  operated  upon  in 
front,  and  kept  in  camp  till  nearly  cured,  when  they  were 
transferred  to  the  large  fixed  hospitals  on  the  Bosphorus  and 
Dardanelles,  or  sent  to  Smyrna.  If  sick,  a  visit  to  one  of 
the  sanitaria  was,  latterly,  often  substituted  for  a  voyage 
across  the  Black  Sea.  The  ample  accommodation  and  pro- 
vision in  camp  enabled  all  this  to  be  accomplished  toward 
the  end  of  the  war;  but,  at  the  earlier  period,  both  sick  and 
wounded  were  sent  at  once  to  Scutari,  where  the  required 
operations  were  in  most  cases  performed.  Thus,  after  the 
Alma,  the  wounded  and  those  operated  on  were  put  on 
board  ship  within  forty-eight  hours,  and  so  also  after  the 
25th  and  26th  October,  and  especially  after  Inkerman,  when 
the  wounded  were  sent  from  camp  at  a  very  early  date. 

Thus,  then,  it  is  of  much  consequence  to  remember,  in 
order  to  appreciate  aright  the  surgical  annals  of  the  war, 
that,  at  two  epochs  of  the  siege,  arrangements  totally  differ- 
ent were,  from  necessity,  followed  in  the  treatment  and  dis- 
tribution of  the  sick  and  wounded.  It  can  easily  be  under- 
stood what  a  difference  such  arrangements  must  have  made 
in  the  mortality,  after  the  receipt  of  such  an  injury  as  a  com- 
pound fracture.  How  different  it  was  to  keep  a  patient  so 
circuuistanced,  in  a  comfortable  hospital  in  camp,  and  treat 
him  among  his  comrades,  from  having  him  transferred,  im- 
mediately after  the  accident,  in  a  jolting  carriage,  over  roads 

*  The  French  had  ambulances  in  the  ravines  close  down  to  the 
trriiclies.  where  operations  were  much  performed,  with  dressing,  the 
oxfracfion  of  balls,  etc.  From  these  they  p-issed  on  their  wounded 
to  the  divisional  ambulances,  in  one  of  which  (the  right)  Baudens 
tells  us  they  have  had  as  many  as  150  capital  operations  wi'liin 
twenty-four  hours  after  one  sortie,  and  in  another  (the  left)  they  hud 
as  many  as  400  wounded  men  carried  in  the  course  of  one  night, 
that  of  the  lst-2d  of  May,  1855. 


52  SURGERY   OF    THE    CRIMEAN    WAR. 

full  of  mud-pits,  and  in  the  close  hold  of  a  crowded  trans- 
port, over  a  sea  proverbially  stormy,  to  be  disembarked,  in  a 
manner  the  most  faulty  conceivable,  at  Scutari,  admitted 
among  strangers  into  a  great  hospital  at  a  period  when  the 
fever  occasioned  by  his  wound  was  at  its  height,  and  placed 
under  the  care  of  a  surgeon  who  knew  nothing  of  his  pre- 
vious history,  or  the  particulars  of  his  case  I*  The  deplor- 
able effect  occasioned  by  this  early  transference  I  will  allude 
to  more  particularly  afterward. 

The  system  of  nursing  which  was  pursued  in  our  hospitals 
at  the  beginning  of  the  war  was  highly  defective,  and  led,  I 
doubt  not,  to  the  sacrifice  of  many  lives.  The  attendants 
on  the  sick  consisted  exclusively  of  soldiers,  very  often  con- 
valescents, whose  strength  was  not  sufficiently  restored  to 
enable  them  to  resume  duty;  and  not  unfrequently  of  the 
worst  set-up  and  most  useless  of  the  privates,  whose  presence 
n  the  ranks  could  be  easily  dispensed  with.  These  were 
detailed  for  the  service  of  the  hospitals  in  the  proportion  of 
one  attendant  to  ten  sick,  and  in  the  transports,  in  the  pro- 
portion of  one  attendant  to  twenty-five  sick.  The  necessity, 
during  the  early  part  of  the  war,  of  having  at  his  post  every 
man  who  could  carry  a  musket,  kept  the  number  of  orderlies 
rather  below  than  above  this  proportion,  and  often  occasioned 
the  employment  of  men  utterly  unfit  for  the  duty.  In  hos- 
pitals at  home,  with  few  serious  ailments  among  their  in- 
mates, the  proportion  of  attendants  allowed  by  the  War- 

*  It  was  a  most  serious  error  in  the  transference  arrangements 
that  no  account  of  the  patient  was  transmitted  along  with  him,  when 
he  passed  from  one  hospital  to  another.  It  prevented  the  surgeon 
into  whose  care  he  fell  from  having  the  same  interest  in  him  he 
otherwise  might  have  had,  and  it  obviously  stood  in  the  way  of  his 
proper  treatment,  and  destroyed  most  effectually' all  means  of  ob- 
taining accurate  statistics,  or  enabling  one  to  follow  cases  to  a  term- 
ination. The  naval  authorities  managed  this  much  better,  in  sending 
a  full  account  of  each  patient  when  he  was  transferred;  but,  of 
course,  with  them  this  was  more  easily  effected  than  it  was  with 
soldiers. 


NURSING.  53 

Office  regulations  is  ample;  but  in  field  hospitals  during  war 
the  case  is  very  different,  as  there  the  accidents  are  severe, 
and  few  of  the  patients  are  able  to  assist  themselves.  The 
distance  at  which  the  cook-houses  and  latrines  are  usually 
placed,  in  the  arrangement  of  field  hospitals,  impose  much 
labor  on  the  orderlies,  and  the  discomforts  to  which  they  are 
thenfSelves  exposed  render  them  both  mentally  and  physi- 
cally less  able  to  perform  their  duties. 

The  pensioners,  who  with  so  much  parade  of  "unquenchcd 
courage  "  volunteered  to  serve  in  the  ambulance  corps,  and 
tend  the  sick,  proved  most  useless,  being  but  little  fit  to 
undergo  the  fatigue  which  their  duties  entailed,  and  were, 
with  few  exceptions,  sorely  addicted  to  "a  veteran's  fail- 
ing." They  soon  disappeared,  being,  to  use  a  vulgar  phrase, 
quickly  "used  up."  I  saw  enough  of  civilian  orderlies  to 
impress  upon  me  the  conviction  that  they,  too,  are  ill  fitted 
for  duty  in  military  hospitals  where  it  is  so  necessary  to 
maintain  both  a  military  spirit  and  a  strict  military  discipline. 
They  do  not  understand  the  soldier,  who,  in  his  turn,  despises 
them,  and  thus  an  antagonism,  almost  impossible  to  control, 
springs  up  between  them.  Besides  this,  the  want  of  the  pre- 
vious training  of  military  drill  makes  the  purely  civilian 
orderly  by  no  means  so  manageable  or  so  "  workable"  in  a 
camp  where  he  feels  as  a  stranger,  and  withal,  becomes  some- 
times a  hopeless  burden.  The  recently-formed  medical  staff 
corps  of  our  army  will,  I  believe,  be  found  most  efficient,  being 
an  imitation  of  the  "Infirmiers"  of  the  French  hospitals.* 

*  Steady  soldiers  of  character,  or  men  especially  recruited,  form- 
ing a  distinct  corps,  having  promotion  granted  them  in  it  for  merit, 
retaining  the  military  spirit  and  the  military  idea,  but  still  consti- 
tuting a  separate  fraternity,  well  paid  and  well  fed,  (an  essential  for 
a  sick  atlendan',)  having  fixed  duties  and  regular  training,  not  lia- 
:tl)lo  to  military  service,  entirely  under  the  command  of  the  medical 
officers,  and  yet  subject  to  military  discipline, — such  is  a  rough  out- 
ine  of  the  corps  which  would  ivndor  the  be>t  service  in  the  hospitals 
of  an  army  in  the  field.  Each  hospital  should  have  its  own  staff 

5* 


54  SURGERY  OF  THE  CRIMEAN  WAR. 

Much  has  been  said  about  the  expediency  of  employing 
female  nurses  in  military  hospitals,  and  though  the  question 
admits  of  numerous  arguments  pro  and  con,  on  which  I  can- 
not here  enter,  still  I  have  no  hesitation  in  giving  my  entire 
adhesion  to  the  practicability  and  usefulness  of  this  proposal, 
if  conducted  with  discretion  and  caution.  I  have  seen  much 
of  this  experiment,  and  watched  its  working  with  attention. 
I  believe  that  Miss  Nightingale  has  decided  the  question, 
and  that  under  her  auspices  an  addition  will  be  made  to  the 
regularly  recognized  nursing  arrangements  of  our  military 
establishment  which  will  prove  of  the  very  highest  value. 
The  great  difficulty  will  always  be  to  find  persons  fitted  to 

complete.  Its  non-commissioned  officers  (wardmasters)  of  various 
grades,  its  cooks,  and  its  tradesmen,  and  their  distribution  and  emi- 
gration should  be  entirely  under  the  control  of  the  principal  medi- 
cal officer,  who  should  have  it  in  his  power  to  concentrate  these  men 
or  disperse  them,  as  his  ideas  of  the  exigencies  of  the  service  dic- 
tated, without  reference  to  any  higher  authority  further  than  the 
responsibility  which  the  due  performance  of  the  service  entails. 
The  independence  of  the  "Interidance"  in  the  French  service  of  the 
medical  staff,  and,  in  fact,  the  superiority  of  the  "Intendant"  in 
rank  to  the  surgeon,  and  the  authority  which  is  given  in  their  hos- 
pitals to  the  "Comptable"  over  the  medical  officers,  is  a  decided 
blot  in  their  system.  The  medical  man  is  thus  deprived  of  his 
proper  position,  and  as  his  promotion  depends  on  the  Intendant,  he 
can  hardly  be  expected  to  be  bold  enough  to  expose  omissions  in  the 
management.  It  is  certainly  very  desirable  that  all  the  details  in 
the  economy  of  a  hospital  should  be  completely  managed  by  some 
one  else  than  the  medical  officer,  whose  special  duties  should  alone 
engage  him,  but  the  department  (the  purveyor's  in  our  service)  over- 
looking these  details  should  be  entirely  under  the  control  and  direc- 
tion of  the  medical  men.  How  to  arrange  the  functions  of  the  med- 
ical, commissariat,  and  purveying  officers,  so  as  to  produce  one 
harmonious  whole,  and  not  have  it,  as  at  present,  that  each  should 
be  called  upon  to  serve  half  a  dozen  masters,  is  a  problem  not  easy 
to  solve.  The  general  hospital  system  is,  of  course,  much  more 
favorable  to  the  production  of  a  good  "whole,"  in  this  respect,  than 
subdivisions  into  regimental  hospitals  can  be,  and  in  this  the  advant- 
ages of  such  a  system  are  recognizable. 


FEMALE    NURSES.  55 

undertake  the  duty.  They  must  combine  a  vigorous  body 
with  a  well-balanced  mind — a  mind  a  a  tinctured  by  vain  "ro- 
mance," but  endowed  with  religious  feelings  of  such  depth 
and  strength  as  will  enable  them,  "in  the  name  of  Jesus 
Christ  our  Lord,  in  perfect  chanty  and  self-devotion,"*  to 
undertake  their  trying  duties.  There  must  be  the  most  per- 
fect subjection  to  superiors,  no  "fussiness"  or  nervousness  of 
disposition,  calmness  in  the  hour  of  danger,  and,  above  all, 
a  large  stock  both  of  common  sense  and  of  cheerfulness.  In 
recounting  these  qualifications,  I  do  little  more  than  name 
those  so  pre-eminently  possessed  by  Miss  Nightingale  and 
several  of  our  leading  nurses.  It  requires  the  complete  ab- 
negation of  self-will  which  exists  in  the  Romish  church  to 
produce  the  sceurs  de  charite ;  but  that  the  Protestant 
church  too  can  send  forth  a  band  equally  efficient,  the  "  dea- 
connesses"  of  the  Rhinef  and  our  own  Eastern  hospital 
nurses  have  demonstrated.  That  most  injudicious  selections 
were  in  various  instances  made  for  service  in  our  hospitals, 
few  who  had  much  to  do  with  these  establishments  will  deny ; 
but  every  unprejudiced  and  attentive  observer  must  acknowl- 
edge the  vast  amount  of  good  which  the  female  nurses  accom- 
plished, and  the  incalculable  service  which  they  are  capable 
of  performing  when  judiciously  selected  and  properly  organ- 

*  Instructions  to  the  Superior  of  the  Russian  Institution  for  edu- 
cating Sisters  of  Mercy. 

|  Those  who  are  interested  in  this  question  will  read  with  pleasure 
the  pastor  Fleidner's  personal  account  of  the  Kasierswerth  Institu- 
tion for  the  training  of  denconnesses  which  he  has  published,  as 
well  as  a  short  pamphlet  which  is  believed  to  have  been  written  by 
Miss  Nightingale,  on  the  same  subject,  and  published  in  London  for 
the  benefit  of  the  Invalid  Gentlewoman's  Establishment.  It  shows 
that,  long  before  the  establishment  of  the  order  of  Sisters  of  Mercy 
by  St.  Vincent  de  Paul,  the  office  of  deaconness  existed  in  the  Chris- 
tian church,  as  well  as  how  energetic  the  sisterhood  has  been  since 
iis  revival.  The  dcaconnesses  now  supply  a  great  many  hospitals  in 
Germany  and  elsewhere  with  nurses,  and  the  system  is  rapidly  spread- 
ing to  different  countries. 


56  SURGERY    OF   THE    CRliMEAN    WAR. 

ized.  The  respect,  almost  devotion,  shown  toward  them  by 
the  soldiers,  disappointed  those  who  prophesied  different 
conduct  from  "the  British  ruffian  " 

In  military,  more  than  in  civil  hospitals,  is  the  kindly  sym- 
pathy and  gentle  care  of  a  woman  required.  The  soldier 
has  no  crowd  of  anxious  friends  or  relatives  to  visit  his  sick 
bed ;  but,  oppressed  by  a  sense  of  loneliness  in  a  foreign  land 
— a  feeling  of  which  he  is  little  conscious  when  in  health, 
but  which  comes  upon  him  with  overpowering  weight  when 
the  silence  of  the  sick-room  gives  him  time  for  reflection — 
he  clings  to  those  gentle  offices  of  kindness  which  a  woman 
can  alone  bestow.  To  the  surgeon  a  good  nurse  is  of  incal- 
culable service.  His  medicines  and  splints  cannot  cure 
unless. those  many  trivial  and  apparently  insignificant  points 
connected  with  the  management  of  a  sick-bed,  which  are 
more  than  half  the  cure,  are  attended  to.  The  surgeon  has 
enough  to  occupy  all  his  scant  time  in  the  greater  and  more 
serious  duties  of  his  service;  while  those  nameless,  con- 
stantly-recurring necessities  of  a  sick-room,  none  can  minister 
to  like  a  woman.  To  perform  such  duties  aright  seems  part 
of  a  woman's  mission  on  earth.*  The  patience  and  gentle- 
ness which  are  such  inestimable  qualifications  in  a  nurse,  we 
cannot  look  for  in  a  strong  and  vigorous  man,  nor  yet  that 
sensitive  recognition  of  a  sick  man's  wants  which  so  distin- 
guishes a  woman.  Charles  Lamb  well  expresses  this  idea 
when  he  says :  "  It  is  not  medicine,  it  is  not  broth  and  coarse 
meats  served  up  at  stated  hours  with  all  the  hard  formality 
of  a  prison ;  it  is  not  the  scanty  dole  of  a  bed  to  lie  on, 
which  dying  man  requires  from  his  species.  Looks,  atten- 
tions, consolations,  in  a  word,  sympathies  are  what  a  man 
most  needs  in  this  awful  close  of  human  sufferings.  A  kind 
look,  a  smile,  a  drop  of  cold  water  to  a  parched  lip, — for 
these  things  a  man  shall  bless  you  in  death." 

*  Lutlier  says:  "A  readiness  to  compassionate  others  is  more 
natural  to  woman  than  to  man.  Women  who  love  godliness,  gene- 
rally have  also  a  special  gift  for  comforting  others." 


FEMALE    NURSES.  57 

A  woman's  services  in  a  hospital  are  invaluable,  if  they 
were  of  no  further  use  than  to  attend  to  the  cooking  and 
the  linen  departments,  to  supply  "  extras"  in  the  way  of 
little  comforts  to  the  worst  cases,  to  see  that  the  medicines 
and  wine  ordered  are  administered  at  the  appointed  periods, 
and  to  prepare  and  provide  suitable  drinks.  As  to  the 
employment  of  "ladies,"  I  think  they  are  altogether  out  of 
place  in  military  hospitals,  except  as  superintendents.  As 
heads  of  departments,  as  organizers,  as  overlookers,  "  offi- 
cers"  of  the  female  corps,  if  you  will,  they  cannot  be  dispensed  V 
with  ;  but  for  inferior  posts,  strong,  active,  respectable,  paid 
nurses,  who  have  undergone  a  preliminary  training  in  civil 
hospitals  at  home,  should  alone  be  employed.*  In  the  camp 


*  Deputy  Inspector-General  Mount,  in  his  report  on  the  Russian 
hospitals,  (page  7,)  says:  "From  what  we  saw  and  heard  of  these 
valuable  women,  (Sisters  of  Mercy,)  with  the  previous  knowledge  of 
the  attempt,  to  introduce  female  nursing  into  our  military  establish- 
ments in  the  Crimea  and  at  Scutari,  we  are  led  to  the  conclusion, 
irresistibly,  that  female  nursing,  as  a  general  rule,  can  be  only  suc- 
cessfully practiced  from  either  the  predominance  of  strong  feelings 
of  devotion  or  affection.  Founded  on  merely  mercenary  or  any 
other  feelings,  it  is  not  only  liable,  but  nearly  certain  to  fail  if  intro- 
duced into  military  hospitals;  and  such  we  believe  will  be  the  testi- 
mony of  most,  persons  of  any  experience  who  have  carefully  attended 
to  the  subject  during  the  late  campaign."  It  will  be  observed  from 
the  text  that,  claiming  as  I  do  no  very  limited  experience  of  the 
working  of  the  female-nurse  system,  I  totally  differ  from  my  friend, 
Mr.  Moiiat,  in  his  conclusions  on  one  essential  point,  viz.,  whether 
the  under  nurses  should  be  paid  or  not.  Many  arguments  could  be 
advanced  to  prove  that  they  should  be  paid,  and  well  paid  too;  but 
I  will  content  myself  by  remarking,  that  I  do  not  think  we  can  get 
the  class  of  women  whose  services  are  wanted  in  the  capacity  under 
review,  to  undertake  these  duties  solely  from  "strong  feelings  of 
devotion  or  affection."  Granting  that  the  humbler  classes  are  as 
accessible  to  such  "feelings"  as  are  they  above  them  in  rank,  and 
that  these  prompt  to  many  beautiful  instances  of  self-sacrifice  by 
their  own  "firesides,"  it  is  not  to  be  expected  that,  with  the  circum- 


58          SURGERY  OF  THE  CRIMEAN  WAR. 


\ 


hospitals,  which,  with  an  army  in  the  field,  are  merely  the 
temporary  resting-places  of  the  sick,  men  should  alone  be 
employed  as  nurses ;  but  in  the  more  fixed  hospitals  in  the 
rear,  the  lady  superintendents  and  under  nurses  should,  in 
my  opinion,  always  be  added  to  the  regular  staff.  Their 
attention  should  be  limited  to  the  bad  cases,  and  they  should 
have  the  entire  control  of  the  linen,  medical  comforts,  and 
cooking.  All  cleaning  should  be  done  by  men.  There 
should  be  a  lady  superintendent  over  each  division  of  the 
hospital,  responsible  to  the  surgeon  as  well  as  to  her  own 
lady  chief.  Then  there  should  be  a  store  of  "  extras"  under 
her  charge,  distributable  on  requisition  from  the  medical 
attendant,  and  which  depot  should  be  filled  up  to  a  certain 
quantity  weekly,  the  sister  being  held  accountable  for  the 
contents.  Wine  and  all  extras  should  pass  through  her 
hands.  She  should  be  responsible  for  the  due  performance, 
by  her  female  subordinates,  of  their  duties,  and  have  a  right 
to  interfere  with  the  wardmaster  if  the  cleaning,  etc.  were 


scribed  views  they  have,  they  should  feel  themselves  called  on  to  go 
forth  to  strange  and  distant  lands. 

Even  if  we  did  secure  the  services  of  desirable  persons  whenever 
our  armies  go  abroad,  it  is  well  known  how  difficult,  nay,  how  im- 
possible almost,  it  is  to  control  them  of  that  rank,  when  you  have  no 
other  hold  upon  them  than  that  founded  on  their  feelings.  With  a 
lady,  many  other  influences  come  into  play.  It  becomes  absolutely 
necessary  to  make  the  appointment  "a  good  situation" — one  to  be 
coveted  and  not  lightly  lost — in  order  to  secure  the  services  of,  and 
exercise  the  proper  control  over,  the  class  of  individuals  wanted  to 
fill  the  inferior  posts  My  impression  is,  that,  as  a  body,  the  paid 
nurses  proved  belter  during  the  Lite  war  than  the  unpaid;  and  I 
suspect  a  much  higher  authority  than  miner  could  be  found  fur  the 
statement.  I  do  not  for  a  moment  wish  to  assert  that  religious  char- 
acter is  not  an  almost  essential  qualification  to  be  sought  for  in  the 
nurses  of  all  grades;  but  I  do  not  think  that  we  can  make  the  sys- 
tem work,  if  we  rely  on  religious  feeling  alone  as  the  moving  agent 
to  the  arduous  services  required.  All  the  under  nurses  should,  in 
my  opinion,  obtain  a  handsome  stipend. 


COOKING.  59 

not  properly  attended  to  by  his  male  corps.  Both  ward  mas- 
ter and  sister  should  be  accountable  to  the  surgeon  of  the 
division.* 

There  is  no  part  of  the  organization  of  a  hospital  which 
demands  more  attention  than  the  cooking  department  and 
the  proper  distribution  of  the  food,  and  none  which,  in  mili- 
tary hospitals,  is,  in  general,  more,  neglected.  The  truth  of 
the  maxim  which  says,  "  La  premiere  condition  de  la  sante 
c'est  la  satisfaction  de  l'estomac,"is  beyond  question.  Those 
who  remember  the  cooking  for  the  sick  which  prevailed  at 
Scutari  before,  and  that  introduced  after  the  kitchen  depart- 
ment underwent  the  "female  revolution,"  will  be  able  to 
appreciate  the  difference  which  attention  to  this  point  must 
make  on  the  results  of  treatment.  A  morsel  which  disgusted 
the  healthy  could  hardly  have  been  relished  by  the  invalid, 
and  when  one  calls  to  recollection  the  "  portions"  which 
were  dealt  out  to  the  sick  in  those  days  of  cloud*  he  cannot 
wonder  at  the  awful  mortality  which  reigned,  f  Men  turned 
away  with  loathing  from  the  coarse,  half-cooked,  tough 

*  In  the  cleaning  of  the  wards,  and  attending  to  the  sick,  I  found 
it  a  good  plan,  when  organizing  my  division  of  the  Smyrna  hospital, 
to  divide  the  beds  into  batches  of  sixteen,  to  each  of  which  two 
male  orderlies  were  attached.  Each  of  these  men  was  made  respons- 
ible for  eight  beds,  with  the  floor  and  utensils  included  in  the  space 
occupied  by  that  number  of  beds  One  of  these  men  was  called  the 
"diet  orderly,''  as  his  duty  included  the  bringing  to  the  ward,  and 
the  distributing  of  the  rations  to  the  whole  of  the  sixteen  patients 
included  in  his  division,  and  he  also  attended  the  sister  when  she 
distributed  the  wine  and  extras.  The  other  man  was  the  "medicine 
orderly,"  who  had  charge  of  the  dressings,  and  went  for  and  dis- 
tributed the  medicines  ordered  at  the  visit.  I  found  eight  beds  as 
many  as  one  man  could  properly  arrange,  and  I  confined  the  service 
of  the  two  female  nurses  I  had  in  my  division  to  attendance  on  the 
severe  cases,  the  preparation  of  suitable  drinks,  the  administration 
of  medicines  and  extras,  and  the  changing  of  linen.  The  duties  of 
the  sister  I  have  sketched  in  the  text. 

f  At  the  time  to  which  I  refer,  the  deaths  frequently  ranged  above 
sixty  a  day  at  the  Scutari  hospitals. 


60  SURGERY    OF   THE    CRIMEAN    WAR. 

morsel,  which,  even  if  consumed,  was  incapable  of  providing 
them  with  the  nourishment  they  so  urgently  required.  It 
was  in  the  management  of  those  cases  of  such  frequent  oc- 
currence in  the  East,  where  a  lingering  convalescence — most 
liable  to  relapse — had  succeeded  to  a  wasting  flax  or  debil- 
itating fever,  that  the  "extras"  from  the  "sisters'  kitchen" 
came  to  tell  in  the  treatment.  Nourishment,  properly  and 
judiciously  administered,  was  the  sole  medication  on  which 
we  could  rely  in  such  cases.  It  was  often  of  itself  sufficient 
to  cure,  and  it  was  in  attending  to  this  that  the  female  nurses 
saved  so  many  lives.  I  shall  not  soon  forget  the  change 
effected  by  the  offices  of  the  female  nurses  in  my  division  at 
Smyrna,  by  the  careful  regulation  of  the  diet  alone.  I  do 
not  hesitate  to  say  that,  previous  to  their  arrival,  I  had  lost 
many  patients  whose  lives  I  might  have  been  the  means  of 
saving  if  I  had  had  then  such  assistants.  Though  much  re- 
mains to  be"  said  on  this  subject,  my  space  forbids  entering 
upon  it  further. 

The  transport  of  the  sick  and  wounded  connected  with 
an  active  army  is  always  a  matter  of  difficulty,  and  is  not 
uncommonly  the  indirect  source  of  increasing  the  mortality. 
For  the  array  of  the  East,  the  provision  made  by  the  medical 
department  was  most  ample  ;  but,  unhappily,  military  "  sa- 
gesse"  did  not  always  recognize  the  importance  of  its  being 
carried  out.  Hence,  after  the  Alma,  the  medical  staff  had 
helplessly  to  deplore  the  fatal  abandonment  of  the  forty  am- 
bulance wagons  provided  for  the  service.  In  consequence 
of  this  measure — strongly  remonstrated  against  by  the  med- 
ical staff — the  sick  and  wounded — those  suffering  from  chol- 
era, or  from  broken  bones  and  amputated  limbs — had  to  be 
carried  some  miles  to  the  beach,  under  a  scorching  sun,  either 
in  blankets  slung  between  two  oars,  or  jolted  over  tracks 
deep  with  sand,  in  the  most  uncomfortable  of  all  earthly 
conveyances,  Turkish  arabas.  The  poor  fellows  were  then 
crowded  into  the  hold  of  the  transports,  or  laid  in  rows  on 
the  hard  deck,  with  scarcely  a  single  attendant  to  answer 


TRANSPORT.  61 

their  piercing  cries  for  water,  or  for  a  blanket  to  cover  them. 
That  passage  to  Scutari  is  as  one  of  the  wildest  nightmares 
which  ever  disturbed  an  excited  brain.  Numbers  sank  on 
the  passage,  and  many  died  afterward  from  its  effects.* 
After  the  establishment  of  the  siege,  hospital  wagons  and 
"  cacolets,"  or  mule  litters,  conveyed  patients  to  Balaklava, 
where  they  were  shipped  for  the  Bosphorus  or  England. 

When  the  land  transport  corps  was  fully  organized,  the 
road  to  the  front  finished,  and  the  splendid  line  of  steamers 
established  between  the  Crimea  and  the  Bosphorus,  a  trans- 
port service  existed  such  as,  I  suppose,  was  never  before  seen 
in  the  history  of  war ;  but  before  this  perfection  was  attained, 
much  suffering  had  been  undergone,  and  many  deaths  had 
been  occasioned.  The  scant  conveyance,  rutty  roads,  and 
foul  ships  of  the  first. period  are  now,  with  many  of  the 
earlier  miseries  of  the  war,  almost  forgotten  and  unknown. 
Even  at  the  best  of  times,  all  who  have  watched  the  effects 
of  the  transport  will,  I  think,  acknowledge  the  malignant 
influence  it  directly  and  subsequently  exerted  on  the  wound- 
ed. The  jolting  in  passing  from  camp  to  port,  the  hoisting 
in  and  out  of  ship,  the  close  air  of  the  hold,  the  irregular 
feeding,  the  sea-sickness,  the  decreased  attention  to  dressing, 
and  the  thousand  and  one  hardships  to  a  sick  man  of  a 
conveyance  by  land  and  sea, — all  combined  to  influence  the 
wounded  most  prejudicially,  f  It  was  well  if  the  patient  es- 


*  Out  of  1300  embarked  at  Old  Fort,  51  died  during  the  short 
passage  to  the  Bosphoius.  The  ambulances  were  so  constructed  as 
to  carry  some  men  silting,  and  others  on  stretchers.  The  mule 
litters  also  could  be  made  to  convey  patients  in  either  position. 

f  This  is  strongly  confirmed  by  Dr.  Jenkins,  in  his  report  on  the 
naval  brigade,  when  he  says:  "We  ought  not  to  forget  the  necessity 
there  existed  for  removing  the  men  to  Cossack  Bay  within  a  dny  or 
two  after  operation,  and  the  eifects  of  such  removal.  Those  who 
left  the  camp  in  a  favorable  condition  have  arrived  at  Balaklava  in  a 
state  of  delirium  ;  and  stumps  which  looked  well  in  the  camp  have 
been  found  to  be  in  a  state  of  inflammation  when  the  patients 

G 


62  SURGERY   OP    THE    CRIMEAN   WAR. 

caped  the  deadly  typhus  which  lurked  in  these  ships,  and 
which  brought  death  to  many  who  had  embarked  in  com- 
parative health.  If  he  had  a  broken  limb  or  a  suppurating 
wound,  it  was  more  than  likely  that  an  unhealthy  condition 
would  be  engendered  by  the  accidents  of  the  passage  ;  and 
it  was  lucky  if  gangrene  did  not  ensue,  and  amputation  fol- 
low. The  French  ascribed  much  of  the  gangrene  which 
reigned  in  their  hospitals  at  Constantinople  to  the  early 
transference  of  their  wounded  from  the  camp — a  measure 
which  was  adopted  by  them  in  order  to  maintain  the  morale 
of  the  soldiers. 

Not  a  few  of  our  men  sank  under  the  trial  of  the  voyage, 
and  lie  buried  beneath  the  restless  waves  of  the  Euxine  ; 
while  to  stand,  as  I  have  often  done,  on  the  pier  at  Scutari, 
and  watch  the  landing  of  the  survivors,  gave  one  a  most 
vivid  idea  of  the  pernicious  effects  which  the  voyage  occa- 
sioned. Many  I  have  seen  die  while  being  landed ;  and  I 
remember  six  men  in  one  morning  being  disembarked  in  life 
at  the  pier,  and  dying  before  reaching  the  hospital.  The 
complete  prostration  and  exhaustion  written  on  the  faces  of 
all  told  in  characters  which  no  words  can  express  the  sever- 
ity of  the  suffering  through  which  they  had  passed. 

readied  their  destination.  In  short,  the  consequence  to  a  fresh- 
formed  stump,  of  a  three  hours'  jolting  over  a  bad  road,  even  in  the 
best  slung  ambulance,  may  be  easily  imagined.  The  evil  effects  of 
the  journey  to  Balaklava  upon  men  who  were  not  considered  fit  cases 
for  operation  were  so  obvious  that  latterly,  excepting  for  the  slightly 
wounded,  ambulances  were  never  used,  and  all  the  men  who  had 
undergone  severe  operations,  or  had  been  badly  wounded,  were  con- 
veyed on  stretchers  borne  on  men's  shoulders."  Dr.  Davidson,  of 
Therapia  hospital,  says,  in  his  part  of  the  same  report:  "So  utterly 
prostrated  were  these  men  (patients)  when  they  arrived,  that  the 
wonder  was,  not  that  so  many  died,  but  that  so  many  recovered." — 
Report  on  Baltic  and  Black  Sea  Fleets,  pp.  37  and  47. 


CHAPTER  III. 

The  Campaign  in  Bulgaria,  and  its  Effects  on  the  subsequent  Health  of 
the  Troops — The  Diseases  which  appeared  there,  and  during  the  Flank 
March,  as  well  as  afterward  in  the  Camp  bcf'on-  S«-l>;istopol. 

IN  the  previous  chapters  I  have  described  the  position 
occupied  by  the  British  army  before  Sebastopol,  as  well  as 
its  condition  in  regard  to  food,  clothing,  and  duty.  To 
avoid  confusion,  I  have  hitherto  omitted  to  trace  the  inci- 
dents of  the  earlier  part  of  the  war,  as  they  bore  on  the 
health  of  the  troops;  and  I  have  not  yet  mentioned  the 
diseases  which  prevailed  at  different  seasons  in  our  camp. 
Before  entering  on  the  subject  proper  to  this  volume,  I  must, 
however,  advert  to  these  points,  though  very  briefly,  as 
their  effects  on  the  constitutions  of  the  men,  and  on  their 
recovery  from  wounds  and  injuries,  were  both  great  and  long 
continued. 

It  is  easy  to  infer  that  the  adverse  circumstances  before 
mentioned  must  have  had  a  powerful  influence  in  giving  rise 
to  many  of  the  diseases  which  appeared,  as  well  as  in  caus- 
ing the  strange  rebelliousness  which  marked  some,  and  the 
absolute  incurability  which  characterized  others. 

Early  in  June,  1854,  as  gallant  and  splendid  an  army  as 
Britain  ever  equipped  landed  at  Varna.  Its  numbers, 
amounting  at  that  time  to  15,000,  were  soon  augmented  by 
the  addition  of  upwards  of  10,000.  For  nearly  three 
months  it  acted  as  an  army  of  observation,  having  its  en- 
campments scattered  between  the  coast  and  Shumla,  and 
lying  in  close  neighborhood  to  large  bodies  of  French  and 
Turks,  whose  combined  force  could  not  be  less  than  30,000 

(63) 


64  SURGERY   OF    THE   CRIMEAN    WAR. 

men.  This  large  body  of  troops  was  chieHy  concentrated 
about  Varna,  stretched  along  the  valley  behind  the  town,  or 
crowning  the  neighboring  heights  with  their  white  tents. 

The  country  in  which  our  army  lay  was  of  the  most  beau- 
tiful description  to  the  eye,  but  of  the  most  dangerous  char- 
acter to  the  health.  The  long,  shallow  lakes,  exuberant, 
low-lying  woods,  thick-tangled  wild  flowers,  and  verdant 
grass  presented  to  the  eye  of  all  but  the  initiated  one  of 
the  most  charming  stations  for  an  inactive  army.  But  to 
those  who  judged  of  encampments  by  other  tests  than  those 
of  natural  beauty,  all  these  charms  were  but  as  the  fair 
painting  on  the  cheek  of  death.  Every  element  of  its  physi- 
cal character  was  bad.  Large  surfaces  of  shallow  water, 
surrounded  by  level,  spongy  lands,  indented  with  little  hol- 
lows, dried  and  cracked  by  the  recession  and  evaporation  of 
the  winter  floods ;  low  brushwood,  rank  in  vegetation ; 
bounding  uplands, — these,  with  a  high  temperature,  and  a 
deficiency  of  potable  water,  supplied  nearly  all  the  possible 
combinations  of  physical  destructiveness.*  When  these 
features  failed  to  warn,  the  ominous  designation  of  "  the 
valley  of  death,"  which  the  natives  gave  to  part  of  the 
locality,  could  not  prevent  the  "experimentum  crucis"  being 
made,  and  so  our  splendid  army  was  placed  within  the  vor- 
tex of  these  baneful  agencies,  and  its  fate  was  not  long  left 
in  doubt.  The  crowded  burying-place  of  the  Russians  in 
the  "old  war"  formed  part  of  the  encampment  occupied  by 
the  British,  and  thus  friend  and  foe  lie  mouldering  in  the 
same  graves. 

During  the   period  of  the  year  when  our  army  occupied 


*  "The  experience  of  all  ages  has  proved  that  the  neighborhood 
of  marshes,  grounds  subject  to  be  overflowed  by  large  rivers,  sur- 
rounded by  foul,  stagnating  water,  or  low  places  covered  with  wood, 
are  most  injurious  to  health,  and  the  noxious  effluvia  arising  from 
these  situations  are  augmented  in  proportion  to  the  heat  of  the 
climate  or  the  season  of  the  year." — Sir  George  BallingalVs  Outlines, 
p.  50. 


THE   CAMPAIGN   IN    BULGARIA.  65 

Bulgaria,  the  two  most  prominent  climatic  features  were  a 
hot  sun  in  the  daytime,  (90°  to  98°,)  and  cold,  dewy  nights. 
The  heavy  mists  which  rose  from  the  steaming  lakes  in  the 
valley  spread  their  heavy  mantle  over  the  camp  at.  night, 
and  introduced  into  the  bodies  of  the  unconscious  sleepers 
the  seeds  of  future  disease  and  death.  That  many  who 
escaped  the  immediate  effects  of  such  a  residence,  then 
imbibed  a  poison  which  afterward  showed  itself  in  their 
behavior  under  injury,  few  will  question,  who  watched  the 
phases  of  disease  during  the  subsequent  periods  of  the  war. 

The  rationing  of  the  troops,  too,  when  in  Bulgaria,  was 
bad  and  irregular,  the  tents  thin  and  permeable,  and  an 
ample  supply  of  deleterious  spirit  and  adulterated  country 
wine  at  hand.  These  all  lent  their  aid  in  predisposing  to 
the  outbreak  of  disease. 

The  apathy  which  these  causes,  and,  above  all,  the  want 
of  employment,  engendered,  all  tended  in  the  same  direc- 
tion, so  that  when  cholera  broke  out  in  July,  a  better  field 
for  its  ravages  could  hardly  be  imagined.  The  power  which 
terror  has  in  propagating  this  disease  received  many  most 
striking  exemplifications  at  this  time.  The  French  and 
Turks  suffered  most.  The  horrors  of  their  hospitals  recalled 
the  pictures  of  Boccaccio.  Half  of  the  army  of  Espinasse, 
in  the  Dobrutscha,  disappeared  as  by  a  whirlwind,  and  the 
panic  which  seized  the  survivors  has  been  described  to  me  as 
having  been  beyond  belief.  This  cholera  was  the  great 
scourge  which  devastated  our  camp  ;  but  typhus,  its  close 
companion,  diarrhea,  and  dysentery,  all  claimed  their  tithe 
of  men.  The  breaking-up  of  the  large  encampments  failed 
.  to  rid  us  of  the  enemy,  which  clung  to  our  army  with  a  per- 
tinacity and  malignancy  that  nothing  could  overcome.  Thus, 
then,  in  less  than  three  months  we  find  that  897  died  from 
cholera,  and  75  from  dysentery  and  diarrhoea.  The  Light 
Division,  the  Guards,  some  of  the  heavy  dragoon  regiments, 
and  the  commissariat  department  appear  to  have  been  the 
heaviest  losers. 

6* 


66  SURGERY  OP  THE  CRIMEAN  WAR. 

It  is  not,  however,  for  the  purpose  of  repeating  the  tale 
of  the  heavy  losses  of  our  army  in  Bulgaria,  that  I  make 
these  remarks.  It  is  in  order  to  indicate  what  a  weakening 
and  deleterious  effect  the  residence  in  that  country  exerted 
on  the  survivors,  and  how  much  its  effects  must  have  told  on 
the  issue  of  disease  and  accident  afterward.  There  is  no 
one  fact  which  more  completely  illustrates  this  pernicious 
influence,  than  what  all  surgeons  who  served  in  Bulgaria 
will  remember,  that  numbers  of  men,  without  being  abso- 
lutely diseased,  or  yet  so  ill  as  to  be  fit  for  hospital,  or  per- 
haps even  for  medical  treatment  of  any  kind,  yet  fell  off  in 
appearance,  lost  appetite,  flesh,  and  color,  became  listless 
and  weak ;  and  that  almost  every  one  who  had  seen  the 
campaign  out,  was  conscious  of  a  considerable  difference  in 
his  state  of  health  after  he  landed.*  The  standard  of 
health,  in  short,  was  lowered,  the  vital  forces  were  dimin- 
ished previous  to  embarkation  for  the  Crimea  in  September; 
and  though  a  state  of  sickness  had  not  been  established  yet, 
that  prelude  to  it  existed  which  wanted  only  a  determining 
cause  to  develop  it. 

This  "unsatisfactory  condition"  was  well  shown  during 
the  short  marches  to  the  place  of  embarkation,  by  the  num- 


*  The  very  serious  effect  -which  inaction  has  in  determining  disease 
in  an  army  needs  no  illustration.  The  annals  of  the  Peninsula 
afford  many  examples.  That  a  much  less  proportion  of  sick  existed 
in  the  Peninsula  when  the  army  was  fighting  and  marching  daily, 
than  existed  in  our  army  in  Bulgaria  when  no  duty  almost  had  to  be 
performed,  is  only  in  keeping  with  many  other  facts  of  the  same 
character  spread  broadcast  over  the  pages  of  history.  "My  esti- 
mates lead,"  says  Dr.  Aitken,  "with  still  greater  force  to  the  conclu- 
sion, that  the  amount  of  sickness  at  Varna  was  greater  than  that  of 
the  French  army  in  Spain,  and  nearly  as  great  as  the  army  of  Por- 
tugal while  engaged  in  very  active  campaigns,  and  this,  too,  though 
not  a  soldier  in  Lord  Raglan's  army  had  fired  a  shot."  "The  period 
of  smallest  loss  to  an  army,"  says  Mr.  Alcock,  "is  a  victorious  and 
vigorously  prosecuted  campaign,  with  frequent  battles  and  much 
marching." 


THK    CAMPAIGN    IN    BULGARIA.  fit 

her  of  men  who  "fell  out,"  and  the  large  proportion  who 
were  unable  to  carry  their  packs.  It  was  also  officially 
recognized  in  the  order  by  which  the  commanding  officers  of 
regiments  had  the  option  of  making  the  men  land  without 
their  kits,  on  disembarkation  at  Old  Fort. 

There  is  no  donbt  that  the  spirit  infused  into  the  men  by 
the  prospect  of  employment  had  a  good  effect  on  their  health 
at  the  period  of  embarkation  for  the  Crimea,  but  still  the 
cholera  did  not  leave  them.  From  some  of  the  transports 
burials  took  place  daily  during  the  transit  to  Old  Fort. 
The  heavy  rain  which  drenched  the  unsheltered  army  during 
its  first  bivouac  gave  the  disease  a  fresh  impulse ;  and  when, 
after  the  Alma,  one  of  the  first  principles  which  regulate  en- 
campments was  violated  by  our  men  being  halted  on  ground 
lately  occupied  by  the  enemy — an  enemy,  too,  among 
whom  cholera  had  prevailed  —  and  camped  amid  the  dirty 
straw,  old  rags,  and  filth  which  the  Russians  always  leave 
behind  them  in  such  profusion,  the  disease  broke  out  with 
violence. 

In  the  vineyards  of  the  Balbec  our  soldiers  ate  voraciously 
of  the  grapes  which  there  hung  in  such  tempting  clusters, 
and  drank  immoderately  of  the  streams  which,  splashed  and 
muddied  by  the  hot  wheels  of  tumbrils  and  guns,  and  the 
dusty  feet  of  many  men,  filled  their  parched  mouths  with 
sand.  Connect  all  this  with  the  most  exhausting  fatigue — 
a  fatigue  which  caused  the  immediate  death  of  some — with 
the  dreadful  heat,  the  excitement,  the  want  of  food  and 
sleep,  and  then  it  will  be  easily  understood  why  596  men 
sank  during  the  famous  flank  march,  and  2237  were  sent  off 
sick  therefrom  to  Scutari,*  as  well  as  that  many  arrived  before 
the  city  utterly  exhausted,  and  that  many  never  fairly  got 
over  the  effects,  engaged  as  they  were  almost  immediately 
in  their  arduous  trench  duties,  and  thus  deprived  of  any 

*  See  paper  by  Dr.  William  Ait  ken  in  Glas.  Med.  Jow-nal  for 
April,  18.r>7. 


68  SURGERY  OF  THE  CRIMEAN  WAR. 

opportunity  of  repose  or  recovery.  Those  men  whom  ill- 
ness or  fatigue  prevented  from  keeping  up  with  their  com- 
rades were  left  behind  to  take  their  chance,  as  there  was  no 
conveyance  to  carry  them  on;  and  both  from  this  cause,  and 
from  the  deficiency  of  opium  in  the  chests  to  meet  the  de- 
mand, many  lives  were  lost. 

Thus,  then,  in  the  short  period  of  three  months  in  Bul- 
garia, and  the  twenty-two  days  which  elapsed  between  the 
landing  in  the  Crimea  and  the  camp  being  formed  before 
Sebastopol,  a  very  large  number  of  lives  were  lost,  and  the 
seeds  of  much  of  that  sickness  sown  which  yielded  such  a 
rank  harvest  afterward. 

The  troops  were  without  tents  for  some  weeks  after  land- 
ing, their  packs  were  not  returned  to  them  for  nearly  two 
months  after  the  establishment  of  the  siege,  and  their  squad 
bags  not  having  been  forwarded  from  Scutari,  "the  soldier 
was  left  during  the  interval  almost  in  rags,  a  prey  to  vermin, 
and  without  a  change  of  any  kind,"  (  Tulloch,)  all  this  while 
undergoing  great  fatigue  and  much  exposure. 

Thus,  then,  I  have  rapidly  sketched  the  progress  of  the 
expedition  up  to  the  sitting  down  of  the  army  before  Sebas- 
topol, and  indicated  the  leading  circumstances  which  exer- 
cised an  influence  on  the  health  of  the  troops.  Let  me  now 
shortly  inquire  what  were  the  diseases  which  resulted  from 
these  circumstances,  and  from  those  other  conditions  that 
came  into  play  at  a  later  period — already  traced  in  a  pre- 
vious chapter — which  all  combined  to  destroy  10,000  men  of 
our  army  in  seven  months,  and  to  delay  the  fall  of  the  for- 
tress for  a  year. 

It  is  a  remark  of  all  times,  that  disease  thins  the  ranks  of 
an  army  far  more  than  is  done  by  the  arms  of  an  enemy. 
The  ignorant  and  unreflecting  dwell  more  upon  those  events 
which  are  of  unusual  occurrence,  while  they  pay  but  little 
attention  to  the  effect  of  those  causes  with  whose  action 
they  are  familiar.  Thus  it  is,  that  to  the  unthinking  ob- 
server, the  ravages  of  battle  present  themselves  with  greater 


DISEASES   OF   THE    ARMY.  69 

force  than  the  more  obscure  but  more  deadly  influences  of 
disease. 

The  proportion  in  which  the  victims  of  disease  will  ex- 
ceed those  of  battle  varies  with  the  country  and  the  season 
in  which  the  campaign  is  waged,  as  well  as  with  the  re- 
sources of  the  army  engaged.  It  was  a  saying  of  Frederick 
the  Great,  that  fever  alone  cost  him  more  men  than  seven 
pitched  battles,  and  it  has  been  an  axiom  with  most  com- 
manders, that  "  more  campaigns  are  decided  by  sickness  than 
by  the  sword."  At  Walcheren,  in  1809,  our  army,  number- 
ing 40,000,  lost  332  in  the  thousand  by  disease,  and  only 
16 -7  by  wounds.  In  the  Peninsula,  from  January,  1811, 
to  May,  1814,  during  which  period  the  battles  of  Albuera 
— "the  most  desperate  and  bloody  of  the  whole  revolution- 
ary war" — Salamanca,  Yittoria,  the  Pyrenees,  Nivelle,  Nive, 
Orthes,  and  Toulouse  were  fought;  and  Badajos,  Ciudad 
Iloddgo,  and  San  Sebastian  stormed,  besides  many  lesser 
encounters,  in  an  efl'ective  force  of  61,500  men,  only  42'4 
per  1000  were  lost  by  wounds,  while  118'6  were  lost  by  dis- 
ease. In  Burimih,  again,  under  a  less  propitious  climate, 
in  the  first  war  35  per  1000  were  lost  by  wounds,  and  450 
per  1000  by  disease;  and  in  the  following  year  106  6  per 
1000  were  lost  by  battle,  and  300  per  1000  by  disease.* 
In  the  Indian  campaigns,  in  the  wars  of  the  Empire,  and  in 
lite  Russian  campaign  against  Turkey  in  1828,  the  difference 
is  still  more  marked.  To  multiply  examples  would  be  of 
little  use,  but  sufficiently  easy,  as  the  same  is  the  teaching  of 
almost  all  campaigns. 

In  the  Crimea  the  proportion  of  those  lost  by  sickness  to 
those  lost  by  wounds  was,  if  we  take  the  whole  war,  as 
16,211  to  1761  ;f  and  if  we  calculate  merely  the  period 

*  I'.audorfs  HygK'iie  Militaire  compan'i-.  The  experience  of  tho 
French  in  Kg\  pt  is  an  exemption.  There  they  lost  -\\~>~  by  disease, 
:md  I7")S  by  wounds  and  accidents,  in  an  army  of  oO.OOO,  and  in  a 
period  of  three  years  and  a  half. 

j-  Not  including  those  killed  in  action. 


TO  SURGERY  OF  THE  CRIMEAN  WAR. 

from  October,  1854,  to  April,  1855,  then,  in  a  mean  strength 
of  23,775  men,  we  have  9248  lost  by  sickness  to  place 
against  608  lost  by  wounds;*  or  if  we  extend  the  period, 
and  number  the  loss  in  strength  by  disease  and  wounds 
from  October,  1854,  up  till  the  conclusion  of  peace  in  1856, 
then  the  contrast  becomes  yet  more  marked  and  decided. 
In  the  French  and  Russian  armies  engaged  during  the  war, 
I  believe  the  proportion  of  disease  to  wounds  to  have  been 
even  higher  than  in  ours  ;  but  the  want  of  accurate  details 
prevents  any  close  approximation  to  their  loss  being  made. 
M.  Scrive  tells  us  that  in  December  and  January,  1854-55, 
their  admissions  into  the  Crimean  ambulances  were  15,500, 
of  whom  14,000  were  for  disease,  and  1500  wounded;  that 
of  the  whole  number  1700  died;  and  that  during  the  last 
six  months,  in  which  the  final  assaults  that  led  to  the  taking 
of  the  city  were  made,  the  French  had  21,957  wounded,  and 
101,128  cases  of  disease. 

It  has  been  calculated  that  during  a  campaign,  an  average 
of  10  per  cent,  sick  may  be  looked  for;  but  in  the  Crimea 
the  average  was  very  much  above  this,  as  at  one  time,  (Octo- 
ber, 1854,  to  April,  1855,)  even  though  our  army  was  sta- 
tionary, in  a  comparatively  healthy  climate,  having  its  com- 
munications open,  and  within  a  few  miles  of  the  sea,  the 
percentage  of  sick  to  strength  rose  to  39  per  cent,  for  the 
whole  body  of  infantry,  to  45  per  cent,  for  the  troops  serv- 
ing in  front,  and  for  eight  corps  to  the  unheard-of  number 
of  73  per  cent  The  average  percentage  of  sick  to  strength 
during  the  whole  war  cannot  be  ascertained  with  precision. 

The  diseases  which  chiefly  affected  our  troops  were  cholera, 
diarrhoea,  dysentery,  typhus,  and  typhoid  fevers.  It  is  true 
that  some  of  these  were  often  so  mingled,  so  confounded  in 
their  manifestations,  and  so  modified  by  their  mutual  reac- 
tions, that  it  was  not  always  easy,  nor  sometimes  possible, 
to  detect  their  individual  influences,  or  their  mutual  correla- 

*  Tulloch's  Crimean  Com.,  p.  152. 


CHOLERA.  71 

tions  and  interdependence  on  one  another;  yet  in  many 
cases  the  distinctions  were  well  marked  at  first,  or  their  in- 

"f*     f 

viduality  was  shown  during  treatment.  The  scurvy  poison- 
was  the  fusing  medium,  if  I  may  so  express  myself,  which 
blended  the  one  disease  into  the  other,  and  modified  all; 
and  as  the  affection  was  more  developed  among  the  French 
than  among  us,  I  believe  the  confusion  of  nosological  dis- 
eases to  which  I  have  referred  was  more  striking  with  them 
than  even  with  us.*  This  curious  confounding  of  affections 
often  put  one's  previous  notions  of  disease  completely  at 
fault,  rendering  the  diagnosis  uncertain,  the  indications  for 
treatment  curiously  at  variance,  and  combining  the  patho- 
logical results  in  unaccustomed  synthesis. 

The  intermediary  position  which  the  Crimea  occupied 
between  Europe  and  Asia  seemed  to  have  caused  that  cor- 
relation of  disease  from  which  our  troops  suffered.  The 
typhoid  fevers  of  European  armies,  and  the  violent  dysen- 
teries of  Asian  and  African,  there  met  and  struggled  for 
the  ascendency;  while  the  omnipresent  cholera  ravaged  our 
ranks,  and  scurvy,  the  product  of  no  particular  clime,  but 
of  man's  own  improvidence,  prepared  the  way  for  their 
several  assaults. 

In  the  returns  of  the  war,  4513  deaths  appear  from 
cholera.  The  whole  number  treated  was  7575,  giving  a 
percentage  of  59 -57  deaths  on  the  whole  number. f  The 
great  majority  of  these  occurred  before  leaving  Varna;  but 
subsequently  to  that  period  two  distinct  outbreaks  of  the 
epidemic  took  place — one  in  December,  1854,  and  the  other 
in  May,  1855.  This  was  the  disease  which  chiefly  attacked 
the  new  drafts,  among  whom,  however,  it  was  not  so  deadly, 


*  My  friend  Professor  Tholozan  has  given  a  very  able  exposition 
of  this  mixing  in  his  paper  read  to  the  Academy  of  Medicine  in 
September,  iy~>(i.  « 

f  These  numbers  do  not  include  offic*  rs,  of  whom  147  died  during 
the  war  of  sickness,  and  86  of  wounds. 


12  SURGERY   OF    THE   CRIMEAN    WAR. 

in  proportion  to  those  seized,  as  it  was  among  the  old  cam- 
paigners. The  period  when  the  disease  was  at  its  greatest 
height  in  the  Crimea  wa,s  in  December,  1854,  when  888 
cases,  in  an  average  strength  of  29,121,  appeared,  and  636 
died — giving  2 '9  per  cent,  cases  of  the  whole  force,  and  71  '6 
per  cent,  deaths  on  admissions.  In  the  June  epidemic  the 
French  had  5450  cases  of  cholera,  of  which  2730  died.  Its 
rebelliousness  to  treatment  was  always  marked  during  the 
period  of  intensity,  and  its  manageableness  during  its  retro- 
cession. There  seems  good  reason  to  suppose  that  the 
cholera  which  appeared  at  Yarna  was  introduced  from  Mar- 
seilles, where  it  was  then  prevalent;  and  while  for  consider- 
able periods  it  remained  quiescent,  it  never  wholly  ceased  in 
the  camp,  until  its  disappearance  in  the  end  of  February. 

Scurvy  was  the  great  destructive  agent  against  which  it 
was  most  difficult  to  cope,  and  which,  though  but  little  cog- 
nizable by  its  usual  signs — though  often  carefully  masking 
its  presence  behind  some  other  ailment — yet  influenced  every 
disease,  and  touched  with  its  poisoned  finger  every  wound. 
Sometimes  breaking  out  with  a  malignancy  which  recalled 
the  graphic  descriptions  of  the  early  voyagers,  or  the  mas- 
terly delineations  of  Lind,  but  more  commonly  declaring  its 
presence  by  a  more  negative,  though  not  less  baneful  influ- 
ence, in  preventing  or  retarding  cure.  Wasting  fluxes, 
occurring  during  the  treatment  of  an  injury  and  defying 
cure  ;  hemorrhages  of  frequent  repetition  and  difficult  sup- 
pression ;  fractures  refusing  to  unite  ;  sores  unaccountably 
slow  to  heal,  were  its  most  ordinary  indications  to  the  sur- 
geon. With  us  it  was  not  often  the  immediate  cause  of 
death ;  but  with  our  allies  it  very  frequently  was.  During 
the  cold  weather  they  lost  many  scorbutic  patients  rapidly, 
from  effusion  into  the  lungs,  and  suffered  far  more  from 
scurvy  than  we  did.  The  sloughing  buboes  in  the  axilla  and 
groin  which  they  had  to  contend  with  were  among  its  worst 
complications.  M.  Scrive  says  that  its  outbreak  was  most 
marked  in  the  regiments  newly  landed,  in  the  proportion  of 


SCURVY.  73 

25  per  cent,  to  10  per  cent,  among  the  older  regiments,  and 
that  it  was  less  in  the  besieging  than  in  the  observing  army 
in  the  valleys  in  the  rear.  With  us,  the  earlier  and  most 
usual  symptoms  of  the  scurvy  were  a  weariness  of  body 
which  indisposed  to  exertion  ;  a  feeling  of  despondency ; 
some  degree  of  dyspnea;  stiffness  in  the  limbs  increased  by 
rest,  and  relieved,  in  a  great  measure,  by  exercise  ;  hardness 
of  the  muscles  of  the  calves  of  the  legs,  the  integuments  of 
which  were  discolored  so  that  they  looked  as  if  peppered 
with  gunpowder ;  and  at  times,  puffiness  of  the  extremities. 
Such  symptoms  were  often  present,  when  the  bleeding  gums 
and  other  more  serious  and  decided  indications  of  the  poison 
were  absent. 

The  omission,  before  adverted  to,  with  regard  to  the  dis- 
tribution of  lime-juice,  had  a  great  influence  on  the  develop- 
ment and  progress  of  this  dyscrasial  disease.  Even  with 
salt  food,  if  a  sufficiency  of  anti-scorbutic  remedies  had  been 
provided,  such  as  well  preserved  vegetables,  in  default  of 
potatoes,  or  other  fresh  legumes,  lime-juice,  or  sour-crout, 
or,  if  the  large  cabbage  of  Turkey,  greatly  praised  by  the 
natives,  had  been  freely  distributed,  the  ravages  of  this  affec- 
tion might  have  been  prevented  or  stayed.  Who  can  calcu- 
late the  number  of  lives  which  were  sacrificed  indirectly,  if 
not  directly,  through  such  omissions  1  for  this  scurvy  was  our 
worst  enemy,  and,  in  truth,  wrested  from  us  more  wounded 
men  than  even  the  conical  ball.*  The  French  used  the  in- 
digenous dandelion  largely,  and  if  the  perseverance  of  their 
soldiers  in  seeking  it  in  every  recess  of  the  plateau  was 
recompensed  by  its  effects,  they  must  have  benefited  largely 

*  Since  such  fruit  as  apples  could  have  been  procured  for  the 
troops  in  large  quantitu-P,  it  is  a  pity  the  authorities  were  unmindful 
of  the  experience  of  Virgil,  who  tells  us,  in  tlie  2d  Georgic,  v.  130, 
of  the  "Felicis  raali".: — 

*  *         "quo  non  pra?sentius  ullum 

*  *•  -*  *  *  *  * 

Auxilium  venit  ;   ac  niembris  agit  atra  venena." 

7 


74  SURGERY  OP  THE  CRIMEAN  WAR. 

by  its  use.  Iron  appeared  to  me  to  have  more  power  over 
this  disease  than  any  of  our  other  remedies.  Under  its  use 
the  blood  assumed  a  more  normal  condition,  and  the  health 
of  the  patient  greatly  improved.  The  French  put  great 
faith  in  the  external  as  well  as  internal  use  of  lemons.  The 
influence  of  scurvy  in  causing  that  curious  eye  affection, 
hemeralopia,  was  frequently  evinced.  It  appeared  at  an 
early  date  among  the  Sardinians,  and  was  not  uncommon 
with  us.  Its  connection  with  deficient  nutrition,  or  with 
a  degenerated  condition  of  the  blood,  was  thus  rendered 
apparent. 

Of  diarrhoea  and  dysentery,  52,442  cases  were  admitted 
into  hospital  during  the  war,  and  5910,  or  11-26  per  cent, 
died ;  while  of  these,  23,149  cases,  and  1999  deaths  occurred 
in  the  Crimea  before  April,  1855.  The  presence  of  scurvy, 
the  use  of  irritating  food,  together  with  the  labor  and  ex- 
posure, sufficiently  account  for  this  high  mortality.  Dr. 
Tholozan  tells  us  that  100  or  800,  out  of  a  total  of  1200 
cases  which  fell  under  his  observation  in  the  Pera  hospital, 
during  the  winter  of  1854-55,  had  suffered  from  diarrhoea 
or  dysentery  at  the  outset  of  their  several  ailments.  In  a 
third  of  these  cases  blood  had  been  passed,  and  in  seventy- 
nine  autopsies  the  large  intestines  were  engaged  sixty-three 
times,  the  small  forty-two  times,  and  the  stomach  thirty- 
eight  times.  From  April,  1855,  to  June,  1856,  compara- 
tively few  cases  of  dysentery  appeared,  showing  how  greatly 
the  improved  hygienic  condition  of  the  army  influenced  the 
development  of  this  "camp  pest." 

Yery  few,  indeed,  who  served  in  the  Crimea  throughout 
the  first  winter  escaped  an  attack  of  dysentery;  and  it  is  in 
keeping  with  my  observation,  that  most  of  those  who  escaped 
entirely  were  officers  who  seldom  ate  the  salt  pork,  but  who 
subsisted  on  fresh  food,'  which  their  private  means  enabled 
them  to  procure.  The  proportion  of  officers  to  men  who 
suffered  from  either  of  the  complaints  specified,  up  to  April, 
1855,  I  have  not  been  able  to  ascertain. 


ULCERATION  OF   THE    INTESTINES.  75 

The  prevalence  of  ulceration  of  the  intestines,  especially 
toward  the  lower  part,  was  perhaps  the  most  constant  of  all 
the  pathological  conditions  found  on  post-mortem  examina- 
tions in  the  East,  and  was  almost  universal  in  cases  of  enteric 
disease.  The  immense  majority  of  those  who  served  during 
the  early  part  of  the  war  were  so  affected,  the  ulceration 
being  rather  of  recent  than  ancient  date;  and  this  remark 
does  not  apply  to  those  alone  who  died  of  abdominal  affec- 
tions, but  also  to  those  who  succumbed  from  other  diseases, 
or  from  wounds.  It  is  also  a  fact,  which  I  have  had  many 
opportunities  of  verifying,  that  men  killed  in  action  at  a 
time  when  they  were  apparently  in  the  possession  of  health, 
or  rather,  as  it  should  be  put,  men  dying  shortly  after  receiv- 
ing severe  wounds  when  seemingly  robust,  were  found  to 
have  ulcers  in  their  intestines,  sometimes  of  a  very  extensive 
character.  To  this  it  was  not  uncommon  to  find  diseased 
kidneys  and  lungs  added.  The  disease,  in  these  cases,  might 
not  be  active  at  the  period  of  death,  but  it  was  ready  to 
break  out  whenever  any  injury  or  operation  made  an  extra 
demand  on  the  powers  of  life.  It  is  of  importance  to  note 
this  extraordinary  prevalence  of  undeveloped  disease — this 
deceptive  character  in  the  appearance  of  the  men — as  bear- 
ing on  their  behavior  under  accident.  The  examples  afforded 
by  post-mortem  examinations  of  intestinal  ulcers  in  all  stages 
of  increase  and  of  cure  were  many  and  interesting. 

The  influence  which  the  intestinal  flux  had,  when  com- 
bined with  scurvy,  to  modify  and  restrain  the  other  mani- 
festations of  the  blood  disease,  and  the  marked  manner  in 
which  abdominal  affections  appeared  to  prevent  the  develop- 
ment of  thoracic  disease  of  a  tubercular  description,  were 
well  exemplified  in  the  Crimea.  This  derivation,  as  it  may 
be  termed,  had  more  to  do  with  the  striking  immunity  from 
phthisis,  which  prevailed,  than  any  goodness  in  the  climate, 
as,  if  it  had  not  been  for  this  counteracting  agency,  the  other 
exciting  causes,  to  which  the  troops  were  exposed  in  such 
abundance,  would  have  been  more  than  sufficient  to  over- 


76  SURGERY  OF  THE  CRIMEAN  WAR. 

balance  the  advantages  of  any  climate.  Of  phthisis,  only 
279  cases  appear  in  the  returns  during  the  whole  war,  and 
116  deaths  in  the  East.  I  know,  however,  that  many  who 
there  showed  no  symptoms  of  the  disease,  subsequently 
succumbed  to  it. 

Of  fever,  (not  typhus,)  30,376  cases  and  3161  deaths 
therefrom  appear  in  the  returns;  March,  1855,  was  the 
month  when  it  most  prevailed,  and  2TO  per  cent,  the  mor- 
tality during  that  month,  and  10 '4  the  percentage  of  mor- 
tality in  the  cases  treated  throughout  the  war.  In  this 
"Crimean  fever,"  there  was  nothing  whatever  peculiar,  un- 
less the  absence  of  any  great  febrile  action,  the  rapid  pros- 
tration, slow  convalescence,  and  proclivity  to  relapse  be 
taken  as  specialties,  which  they  were  not,  in  my  opinion,  as 
in  nothing  did  this  fever  differ  from  the  typhoid  fever  seen 
in  large  cities,  especially  in  Paris.  It  often  followed  dysen- 
tery, which,  by  reducing  the  patient's  strength,  prepared  the 
way  for  this  "fever,"  as  it  was  termed,  but  which,  in  these 
cases,  was  the  mere  development  of  great  vital  prostration, 
with  the  complications  that  were  to  be  looked  for  in  such  a 
sequence.  The  characteristic  spots  were  not  always  present, 
relapses  were  frequent,  and  during  convalescence,  tubercu- 
losis was  not  uncommon.  There  was  always  a  strong  tend- 
ency to  this  fever  evinced  in  our  army.  The  ease  with  which 
it  was  engrafted  on  other  ailments  indicated  the  fall  in  "the 
health  barometer." 

Typhus  fever  killed  285  out  of  828  cases.  The  spring 
months  of  1855  was  the  period  when  it  was  most  prevalent. 
It  was  the  true  maculated  typhus  as  seen  at  home,  with  its 
measly  eruption  appearing  on  the  seventh  or  eighth  day,  and 
not  unfrequently  complicated  with  pneumonia.  This  disease 
was  by  no  means  common  in  our  army,  but  its  ravages  were 
dreadful  among  the  French  and  Russians*  The  much  greater 
crowding  which  existed  in  their  hospitals  probably  accounts, 
much  as  any  other  cause,  for  the  difference.  The  French 
died  of  it  by  thousands,  and  the  Russians  by  tens  of  thou- 


FEVER — J  AL  NDICE.  1  f 

sands.  Neither  I,  nor,  I  believe,  any  other  person,  can  tell 
exactly  how  many  thus  perished,  and  there  is  little  use  in 
speculating  on  numbers.  The  scurvy  played  here  a  most 
important  part,  as,  when  it  was  much  developed,  the  fever 
was  incurable.  I  cannot  say  that  I  had  occasion  to  notice 
those  marked  remissions  in  the  fever  of  the  camp,  of  which 
several  medical  men  have  spoken ;  but  I  am  persuaded  that 
the  treatment  by  large  doses  of  quinine  seemed  to  have  a 
manifest  effect  over  the  low  fevers  of  the  early  part  of  the 
war. 

With  intermittent  fever  we  had  little  to  do;  but  the 
French,  who  were  stationed  along  the  Tchernaya,  suffered 
greatly  from  it,  as  did  the  Russians  in  the  valleys  on  the 
opposite  side  of  the  river.  I  am  not  aware  of  anything 
whatever  peculiar  in  this  fever  as  it  appeared  among  them; 
but  I  have  heard  from  their  surgeons  that  men  subject  to  it 
were  most  unpromising  patients,  if  injured  by  gunshot,  espe- 
cially if  they  combined  any  of  the  scorbutic  taint  with  the 
paludal  poison. 

In  autumn,  jaundice  was  very  prevalent,  though  com- 
monly slight  and  easily  curable  by  a  visit  to  the  Bosphorus ; 
still  it  was  sometimes  very  severe  and  intractable.  The 
mere  change  from  camp  life  and  feeding,  which  took  place 
when  sent  to  sea,  or  to  Scutari,  commonly  "did  the  doctor" 
sufficiently. 

Perhaps  the  symptom  which  most  struck  the  casual  visitor 
to  the  hospitals  during  the  winter  of  1854-55,  was  the  anemic 
appearance  of  the  men.  Their  blood  had  been  so  com- 
pletely depurated,  that  they  had  often  more  the  appearance 
of  chlorotic  females  than  of  soldiers.  It  was  impossible,  in 
a  great  measure,  too,  to  get  the  defect  supplied.  No  treat- 
ment almost  effected  any  change,  and  thus  it  came  to  be  a 
most  serious  affair  if  any  hemorrhage  or  suppuration  had 
to  be  encountered. 

In  this  rapid  review  of  the  diseases  of  the  camp,  I  have 
had  no  wish  to  be  in  any  way  minute.  All  I  intend  by  refer- 

7* 


78  SURGERY   OP    THE    CRIMEAN    WAR. 

ence  to  them,  is  merely  to  indicate  those  which  prevailed, 
that  so  their  bearing  on  the  surgery  of  the  war  might  be 
appreciated.  It  is  clear  that  many  of  them  owed  their  ex- 
istence and  fatality  to  vicious  hygienic  conditions,  of  whose 
influence,  in  deteriorating  the  constitutions  of  the  men,  the 
presence  and  progress  of  these  diseases  afforded  the  best 
proof. 

That  these  diseases  depended  on  the  unfavorable  circum- 
stances as  to  food,  shelter,  and  duty  in  which  the  troops 
were  placed,  has  been  clearly  demonstrated  by  Sir  A.  Tul- 
loch,  as  he  shows  that  the  mortality  varied  in  different  corps 
in  an  exact  ratio  with  the  care  that  was  taken  of  each  in 
providing  them  with  good  food  and  shelter,  even  though 
performing  severe  duties ;  and  that  those  troops  who  were 
constantly  in  the  trenches,  and  badly  supplied  with  clothing 
and  food,  suffered  most.  Thus,  while  the  mortality  among 
eight  corps  in  front  was  as  high  as  73  per  cent.,  and  among 
the  infantry  generally  employed  in  the  trenches  45  per  cent., 
yet,  in  the  naval  brigade,  who  were  always  engaged,  but 
were  well  housed,  clothed,  and  fed,  it  was  under  4  per  cent. 
Among  the  cavalry,  who,  though  perhaps  not  over-well  fed, 
had  yet  no  trench  or  night  duty,  it  was  15  per  cent.,  and 
among  the  artillery,  who  were  well  looked  after,  and  less 
worked,  it  was  18  per  cent. ;  while  among  the  officers,  who, 
though  equally  exposed,  had  yet  the  means  of  obtaining 
better  food  and  clothing,  it  was  only  6  per  cent. 

The  trench  duties  had  certainly  most  to  do  with  the 
mortality,  as  its  dependence  on  the  length  of  time  during 
which  these  "duties  had  to  be  performed  was  very  marked. 
I  will  not  repeat  here  details  with  which  all  are  familiar. 
Sir  A.  Tulloch  has  entered  into  them  at  length.  In 
January,  1855,  the  sickness  had  attained  its  maximum  ;  at 
that  period  the  number  of  those  in  hospital  and  at  Scutaria 
exceeded  the  force  fit  for  duty,  being  as  12,025  sick  to 
11,367  effective. 

I   was   always   strongly   convinced   that   the   Bulgarian 


DISEASES   OF    THE   ARMY.  79 

campaign  exercised  a  great  influence,  not  so  much  on  the 
proclivity  to  disease  as  on  its  fatality  when  formed.     This 
has  been  most  clearly  shown  by  Dr.  William  Aitken,  in  his 
interesting  papers  on  the  health  of  the  troops  at  the  period 
implied.     That  the  effect  of  injury  and  operation  on  these 
men  showed  how  much  their  constitution  had  suffered  during 
their  residence  in  Bulgaria,  I  had  often  reason  to  observe, 
and  an  examination  of  the  returns  shows  that  "  while  the 
admissions  to  hospital  were  so  much  greater  among   the 
Crimean  portion  of  the  army,  the  deaths  per  cent,  on  these 
admissions  were  very  much  greater  among  the  ex-Bulgarian 
part;"  and  that  while  the  Crimean  portion  suffered  chiefly 
from  enteric  and    scorbutic  disease  and  cholera,   the  Bul- 
garian troops  suffered  from  fevers  and  pulmonary  diseases, 
which  is  just  what  might  have  been  a  priori  expected.    The 
mortality  on  admissions  from  fever  was  nearly  double — from 
cholera,   dysentery,    scurvy,   frost-bite    pulmonary   disease, 
much  higher — among  those  troops  who  served  in  Bulgaria 
than  among  those  who  were  only  in  the  Crimea.     I  cannot 
say  how  far  the  paludal  poison  of  the  swamps  of  Yarna  had 
to  do  in  predisposing  the  troops  who  had  imbibed  it  to  fevers 
of  a  typhoid  type.    Dr.  Aitken  appears  to  give  considerable 
weight  to  such  a  predisposition,  and  quotes  the  results  of 
the  Walcheren  expedition  as  affording  an  analogous  instance. 
There  occurred  several  well-marked  instances  to  prove  that 
many  soldiers,  even  some  who  never  had  any  of  the  symp- 
toms of  miasmatic  poisoning  when  in  Bulgaria,  showed  signs 
of  such  an  invasion  when  reduced  by  wounds;  and  I  had 
frequent  occasion  to  remark,  that  the  advent  of  purulent 
contamination  bore  in  such  men  a  more  than  usual  resem- 
blance to  an  attack  of  marsh  fever.     That  the  subtle  influ- 
ence   of    this   poison   had    been    absorbed,   and   afterward 
prejudicially  affected  many  who  did  not  at  first  show  signs 
of  its  presence,  cannot  be  doubted  by  those  who  had  much 
opportunity  of  observing   the  progress  of  disease  and  of 
wounds  in  the  hospitals  of  the  Eastern  army. 


80  SURGERY    OP    THE    CRIMEAN    WAR. 

There  was  an  affection  of  the  hands  and  feet  very  common 
during  the  first  winter  and  spring  in  both  the  English  and 
French  hospitals,  and  which  Dr.  Tholozau,  with  some  of  the 
French  surgeons,  was  inclined  to  look  upon  as  allied  to  a 
peculiar  disease  that  appeared  epidemically  in  France  be- 
tween the  years  1828  and  1832,  and  then  termed  acrodynia. 
I  feel  persuaded  that  with  us  it  was  the  product  of  cold  and 
scurvy,  and  was  perhaps  a  junction  of  rheumatism,  or  yet 
more  probably  of  an  early  stage  of  frost-bite,  with  a  weak 
circulation  and  a  scorbutic  taint.  This  affection  showed 
itself  chiefly  in  the  pulpy  parts  of  the  feet  and  hands,  but 
especially  in  the  ball  of  the  toes,  in  the  edges  of  the  feet, 
and  in  the  muscular  ridge  which  runs  across  the  sole  of  the 
foot  at  the  roots  of  the  toes.  Its  earliest  symptom  was  a 
prickly  sensation  experienced  when  the  patient  stood  on  the 
foot,  and  was  variously  described  by  them  as  resembling  the 
pricking  of  pins,  or  as  if  they  walked  on  nails.  There  were 
lancinating  pains  in  the  calves  of  the  legs,  which  parts  felt 
hard  and  brawny,  and  were  sometimes  swollen  and  dis- 
colored. There  was  weariness  in  the  limbs,  and  a  most  dis- 
tressing heat  in  the  feet,  especially  at  night,  when  the  weight 
of  the  bedclothes  could  not  be  borne.  An  erythematous 
redness  was  often  observed  along  the  edges  of  the  feet  or 
hands,  and  the  sensibility,  though  generally  heightened,  was 
occasionally  diminished,  so  that  they  sometimes  said  that  in 
walking  "they  did  not  feel  the  ground."  It  was  often  local- 
ized in  small  patches,  and  not  always  accompanied  by  other 
scorbutic  symptoms.  It  was  often  combined,  too,  with  low 
fever  or  dysentery,  and  not  unfrequently  followed  by  des- 
quamation  of  the  epidermis,  and  sometimes  by  local  gan- 
grene. 

In  typhoid  fever  and  scurvy,  symptoms  of  a  much  less 
pronounced  character,  but  withal  similar  as  to  numbness, 
formication,  and  hyperresthesia,  are  sometimes  seen  at  home. 
In  India  a  somewhat  similar  affection  of  the  feet,  called  by 


AFFECTION    OF   THE   FEET.  8t 

writers  "burning  feet,"  is  mentioned  by  various  writers*  as 
being  a  most  distressing  disease  of  the  Sepoys,  and  looked 
upon  as  being  a  sequela  of  rheumatism,  and  having  its  origin 
in  the  spinal  cord. 

All  local  treatment  seemed  unavailing  in  the  Crimea, 
though  stimulant  and  anodyne  embrocations,  hot  and  cold 
pediluvia,  and  shampooing  appeared  at  times  to  assuage  it. 
It  disappeared  as  the  general  health  and  the  state  of  the 
blood  improved.  Blisters  were  tried  by  some,  but  were 
manifestly  injurious,  and  at  times  appeared  to  favor  slough- 
ing, from  the  low  vitality  of  the  part. 

It  must  be  allowed  that  this  affection,  as  it  appeared  in 
the  East,  bore  a  very  close  resemblance  to  the  "mal  des 
pieds  et  des  mains,"  as  it  occurred  in  Paris  in  1828.  The 
writers  of  that  periodf  tell  us  of  the  same  pricking  and 
formication  of  the  feet  and  hands,  the  same  streaking  along 
their  edges,  the  same  alternating  heightened  and  diminished 
sensibility,  the  oedema,  dark  patches  on  the  limbs,  and  des- 
quamation  of  the  epidermis,  lancinating  pains,  and  great 
heat  of  the  parts  increased  at  night,  which  were  all  so 
marked  with  us;  but  they  had  occasion  to  notice  many 
severe  symptoms  which  never  showed  themselves  in  our 
patients,  as  delirium,  subsultus  tendinum,  severe  gastric  irri- 
tation, inflammation  of  mucous  surfaces,  (bronchitis,  blenor- 
rhagia,  and  conjunctivitis,)  affections  of  special  senses, 
paralysis,  and  marasmus,  sometimes  followed  by  death. 
Nor  in  France  were  the  local  symptoms  confined  to  the  ex- 
tremities, but  were  sometimes  extended  to  the  face  and  trunk, 

*  See  J.  G.  Malcolmson  on  Rheumatism  and  Burning  Feet.  Mad- 
ras, 1835. 

f  See  Genest  Arch.  Generates  des  Med.,  t.  xviii.  and  xix.;  Char- 
don  fils  Rev.  Med.,  t.  iii.;  Chomel,  Chejoin,  and  Fran9oise  Jour.  Gen. 
de  Med.,  t.  cv.;  Montault  and  Robert,  Do.,  t.  cvi.  and  cviii.;  Brous- 
\n.  de  Med.  Pliys.,  t.  xiv.;  Dance  Die.  de  Mt-d.  O/.anam  Hist, 
des  Epidem.  See  also,  on  a  similar  affection  which  appeared  in 
Padua,  in  17(i2,  Bruj^natelli  Jour.  Physico-Medic. 


82  SURGERY    OF    THE    CRIMEAN    WAR. 

as  is  also  the  Indian  affection  at  times.  In  the  cheiropo- 
dalgia  of  France,  many  of  these  severe  complications  were 
always  present,  and  from  the  circumstances  in  which  the 
epidemic  arose  and  spread,  it  is  impossible  to  connect  it 
either  with  cold,  wet,  scurvy,  or  rheumatism.  It  continued 
with  them  summer  and  winter.  Among  us  it  disappeared 
in  March  with  the  fine  weather  and  the  improved  diet.  In 
France  it  appeared  chiefly  in  robust  and  plethoric  persons, 
whose  symptoms  were  relieved  by  bleeding.  With  us  it  was 
among  those  most  "used  up,"  in  whom  bleeding  would  have 
been  probably  followed  by  gangrene.  In  France  the  disease 
appears  to  have  been  a  mixture  of  convulsive  ergotism  and 
lead  colic  ;  with  us,  an  affection  of  nervous  debility — a  union 
of  weakness,  cold,  and  scurvy.  The  "burning  feet"  of  the 
Sepoy  resembles  much  more  closely  the  acrodynia  of  France 
than  the  Crimean  affection  did.  The  dropsical  effusions, 
spinal  affections,  fatal  complications  "ending  in  extensive 
alterations  in  the  structure  of  the  viscera  of  all  the  cavities," 
and  diffusion  throughout  the  body,  resemble  more  closely 
what  was  seen  in  Paris  than  what  was  manifested  in  the 
Crimea.  In  India  anti-scorbutic  remedies  have  most  power 
in  overcoming  it,  as,  I  should  say,  they  had  also  with  us. 

There  are  various  traces  of  the  occurrence  of  this  affection 
during  the  Peninsular  war ;  but  it  does  not  appear  to  have 
attracted  much  notice  from  surgeons  there.  The  disease 
known  as  beriberi  has,  in  some  of  its  slighter  forms,  a  re- 
semblance to  it,  but  has  many  symptoms  of  which  we  had  no 
experience. 

In  all  these  affections  a  depressed  vitality  and  nervous  ex- 
citement seemed  to  have  been  the  chief  causes  of  disease. 
Dr.  Tholozan  says  he  observed  on  dissection  a  peculiar 
"specific  alteration"  in  the  deep  fatty  tissues  of  the  hands, 
feet,  and  legs,  especially  in  the  borders  of  the  feet,  the  pulps 
of  the  toes,  and  the  thenar  and  autithenar  cushions,  which, 
he  thinks,  has  not  been  as  yet  explained,  and  which  he  does 
not  connect  either  with  scurvy,  fever,  dysentery  or  congela- 


CONCLUSIONS.  83 

tion,  and  which,  as  he  informed  me,  he  believes  to  be  the 
cause  of  the  peculiar  affection  to  which  I  have  made  refer- 
ence above.* 

I  candidly  confess,  I  was  one  of  those  who  looked  for- 
ward with  foreboding  to  the  chances  of  the  plague  appear- 
ing in  our  hospitals ;  but,  providentially,  we  were  spared 


*  "  Le  tissu  graisseux  de  la  plante  des  pieds,  de  la  paume  des 
mains,  ou  bien  celui  qui  forme  le  coussinet  sur  lequcl  repose  le  liga- 
ment rot  alien,  on  bien  les  vesicules  graisseuscs  situees  centre  le  femur, 
au-dessus  de  1'articulation  fernoro-iibiale,  ont  present  <$  27  fois,  dans 
les  79  autopsies,  des  alterations  curieuses.  Avec  un  etat  normal 
du  derme  et  de  Tapon^vrose,  on  trouve  les  vdsicules  graisseuses 
sous-cutanees  fortement  injectees  depuis  le  rouge  clair  jusqifau 
rouge  noir.  La  couleur  jaiinatre  de  la  graisse  a  distant  drrriere  la 
forte  injection,  et  meme  1'etat  ecchymoiique  de  I'enveloppe  cellu- 
leuse  des  vesicules.  Ce  n'est  point  ime  eediymose  sous-cutain'-e: 
c'est  un  etat  anatomiqiic  partu-ulier,  fort  pen  connu  du  tissu  <rrais- 
seux.  Le  tissu  eellulo-tibreaux  intervesiculaire  est  normal  et  plutot 
pale,  les  cellules  graisseuses  sont  tri-s  liyperemt<5es,  et  ces  vesicules 
pve"sentent  quelquefois  a  leur  surface  un  piquete  ecchymotique 
noiratre.  La  graisse  conteuue  dans  les  vesicules  ne  perait  pas 
alteree. 

"Cette  lesion  cxiste  dans  quelques  cas  en  meme  temps  dans  les 
diff(jrentes  regions  indiques;  souvent  mi  ne  la  rencontre  qu'ii  la  plante 
des  pieds  ou  au  voisinage  de  1'articulation  du  genou;  toujours  elle  est 
plus  prononce"e  alaplanfedes  pieds  qu'ala  paume  des  mains.  Le  lissu 
graisseux  le  plus  alter6  est  cclui  qui  avoisine  le  bord  externe  et  le  bord 
interne  du  pied,  celui  des  eminences  thenar  ethypothenar.  Quel<[ucfois 
les  vesicules  graisseuses  de  la  pulpe  des  doigts,  ou  des  orteils  ont  jnv- 
sente  cette  16sion,  mais  ii  un  degre  moindre.  Au  pied  et  a  la  main, 
la  graisse  situe"e  au-dessous  de  1'apon^vrose  n'est  pas  attaquee;  le 
tissu  graisseux  sous-cutan^  ou  profond  des  membres,  ou  des  cavitrs 
splanchnique*  n'offre  rien  d'analogue  a  ces  alterations.  II  ne  nf  a 
pas  6tc  possible  de  saisir  de  relation  entre  cet  etat  et  le  scorbut,  ou 
le  typhus,  ou  la  dyssenterie,  ou  les  congelations.  II  s'agit  la  d'une 
alteration  specifique  non  d^crite,  dont  la  valeur  pathologique  aura  it. 
best. in,  pour  etre  pn'M-isrr,  d'un  plus  grand  nombre  d'observalions." 
— Recherches  sur  leu  Malodies  de  V Armce  d" Orient  lues  a  VAcad.  de  Mcd., 
Sept.  30,  !*-,(;,  rar  M.  le  Dr.  Tholozan. 


84  SURGERY    OF   THE    CRIMEAN    WAR. 

this  fearful  invasion.  Circumstances  were  certainly  favor- 
able to  its  outbreak;  and,  at  one  time,  scurvy  and  malignant 
fever  attained  such  a  mastery  as  to  wear  many  of  the 
features  of  plague,  both  in  the  French  hospitals  at  Constan- 
tinople and  among  the  Russians  at  Odessa;  but  with  us, 
the  rapid  amelioration  which  took  place  as  the  war  pro- 
ceeded made  us  less  nervous  about  any  development  of  it  in 
our  army. 

A  review,  however  superficial,  of  the  medical  annals  of 
the  war^qf/the^hygienic  causes,  and  local  circumstances 
•which  led  to  the  appearance  and  development  of  disease  in 
our  army,  reiterates  in  trumpet-tones  the  same  lesson — 
confirms  and  enforces  the  same  conclusion — that  the  barom- 
eter of  health  rose  and  fell  as  external  circumstances,  favor- 
able or  injurious  to  health,  were  attended  to  or  neglected. 
These  circumstances  were,  in  a  great  degree,  under  our  own 
control,  as  will  always  be  the  case,  whethejMfr  the  camp  or 
the  city.  This  being  so,  it  is  surely  the  first  duty  of  a 
government,  as  well  as  of  a  commander,  to  adopt  every 
possible  precaution  which  can  guarantee  the  health  and  life 
of  the  army  to  which  the  honor,  and  even  the  safety,  of  the 
State  are  intrusted.  By  the  adoption  of  judicious  and 
enlightened  means,  disease,  if  it  cannot  be  wholly  banished 
from  our  camps,!  may  yet  be  stripped  of  the  deadly  power 
which  it  now  so  destructively  wields.  Even  wounds  would 
become  comparatively  harmless,  if  all  the  vital  powers,  (the 
vis  medicatrix  naturse,)  possessed  in  full  vigor  and  activity, 
were  to  put  forth  their  mighty  strength  to  sustain  and 
restore  the  constitution.;!  The  soldier  would  have  no  enemy 
to  fear  but  one  he  could  see  face  to  face — one  whom  the 
British  soldier  never  fears — and  thus  the  effectiveness  of  our 
army  would  be  increased  tenfold. 

Any  one  who  saw  the  two  armies  at  Sebastopol :  the 
ragged,  gaunt,  spectral-like  figures  guarding  their  fated 
trenches  in  the  dreary  winter  of  1854-55,  while  the  majority 
of  their  comrades  lay  in  misery  and  pain  in  the  wretched 


CONCLUSIONS.  85 

hospitals;  and  again  witnessed  the  British  army  in  the 
spring  of  185G:  every  man  in  health  and  vigor — literally 
"full  of  lusty  life,"  and  actually  "rejoicing  in  his  strength," — 
he  who  beheld  that  great  contrast,  and  reflected  how  over- 
sight and  neglect  were  the  causes  of  the  one  sad  picture, 
and  care,  directed  by  knowledge  and  supported  by  energy, 
produced  the  other  truly  glorious  one,  would,  whether 
actuated  by  principles  of  economy,  humanity,  or  patriotism, 
ever  urge  his  country  to  guard  and  preserve  the  health  of 
the  armies  that  defend  it. 

"  Conserver  les  soldats,"  says  Baudens,  "transported  a 
grand  peine,  est  le  premier  interet  d'une  nation  qui  fait  une 
guerre  lointaine;  c'est  aussi  le  meilleur  gage  d'un  succes 
definitif.  Les  maladies  tuent  plus  d'hommes  que  le  fer  et  la 
poudre,  et  il  est  souvent  facile  de  les  prevenir  par  de  sim- 
ples precautions  hygieniques." 


CHAPTER  IY. 

Distinction  between  Surgery  as  practiced  in  the  Army  and  in  Civil  Life — 
Soldiers  as  Patients,  and  the  Character  of  the  Injuries  to  which  they 
are  liable — Some  Peculiarities  in  the  Wounds  and  Injuries  seen  during 
the  late  War. 

THAT  military  surgery  does  not  differ  from  the  surgery 
of  civil  life,  is  an  assertion  which  is  true  in  letter,  but  not 
in  spirit.  As  a  science,  surgery,  wherever  practiced,  is  one 
and  indivisible;  but  as  an  art,  it  varies  according  to  the 
peculiar  nature  of  the  injuries  with  which  it  has  to  deal,  and 
with  the  circumstances  in  which  it  falls  to  be  exercised.  To 
the  surgeon  practicing  in  the  camp,  many  accidents  are 
presented  which  seldom  or  never  come  within  the  observa- 
tion of  the  civil  practitioner ;  while  not  a  few  of  the  cases 
which  are  daily  treated  in  domestic  life,  rarely  come 
under  the  charge  of  the  military  surgeon.  The  two  classes 
of  practitioners  may  be  said  to  be  engaged  in  separate 
departments  of  the  same  profession,  which,  though  uniting 
occasionally,  are  yet  tolerably  distinct  from  one  another. 

The  military  surgeon  during  peace  enters  for  a  time  into 
civil  life ;  but  during  war  he  is  called  upon  to  exercise  the 
very  highest  functions  of  his  profession,  and  has  little  to  do 
with  the  more  trivial  accidents  which  constitute  the  sum  of 
a  private  practitioner's  daily  routine.  His  observation  is 
undoubtedly  restricted  to  a  smaller  variety  of  cases.  He 
sees  less  than  the  civilian  of  the  modifications  which  are 
impressed  upon  disease  by  age  arid  sex;  but  in  war  he  has  a 
wider  field  for  noticing  the  influence  of  external  circum- 
stances, of  extremes  of  climate,  of  variations  in  food,  work, 
and  shelter  on  the  same  men,  as  well  as  the  effects  of  mental 
(86) 


CIVIL   AND    MILITARY    SURGERY.  87 

causes,  as  seen  in  the  exultation  of  victory  and  in  the  pros- 
tration and  dejection  of  defeat. 

But  though  there  may  exist  such  distinctions  between  the 
spheres  of  the  military  and  those  of  the  civil  surgeon,  there 
is  surely  nothing  in  the  exercise  of  their  different  callings 
which  should  create  an  antagonism  between  them.  They 
are  both  members  of  the  same  priesthood,  whose  office  it  is 
to  minister  to  suffering  man,  and  the  experiences  collected 
by  each  should  be  willingly  laid  as  common  offerings  on  the 
altar  of  science. 

To  no  class  of  professional  men  is  a  liberal  education 
more  important  than  to  the  army  surgeon.  To  command 
that  respect  which  is  necessary  for  the  right  exercise  of  his 
official  duties,  he  must  be  superior  in  general  knowledge  to 
his  comrades.  The  many  countries  and  varied  climates  to 
which  he  is  sent,  and  the  delicate  positions  in  which  his  serv- 
ice often  places  him,  demand  the  possession  of  an  enlarged 
and  well-stored  mind ;  while  the  deep  responsibility  at- 
tached to  the  charge  o'f  such  a  number  of  valuable  lives,  and 
the  necessity  imposed  by  the  absence  of  a  "consultant"  of 
deciding  the  most  critical  cases  on  his  own  unaided  judg- 
ment, demand  the  firm  self-reliance  founded  on  clear  knowl- 
edge as  essential  to  any  measure  of  success.  Even  amid  the 
falling  ranks,  where  he  is  exposed  to  as  great  danger  as  any, 
he  must  completely  forget  self,  and  give  his  whole  mind  to 
the  condition  of  the  sufferers  around  him  ;  for  often  do  his 
decisions,  formed  in  a  mere  instant  of  time,  settle  for  life  or 
death  the  fate  of  the  fellow-being  before  him.  Then  his 
powers  of  observation  must  be  so  well  trained  that  he  can 
discriminate  between  different  diseases,  whose  types  are 
mingled  and  masked  by  their  union,  as  these  are  only  seen 
in  armies  in  the  time  of  war. 

The  hardships  incident  to  a  soldier's  life  fall  equally  on  the 
surgeon  as  upon  his  comrades;  and,  besides  the  dangers  of 
battle  and  exposure,  he  runs  the  risk  of  those  epidemic  dis- 
eases which  devastate  armies,  and  which  are  the  product  of 


88  SURGERY   OP   THE   CRIMEAN   WAR. 

exciting  causes,  to  which  he  has  been  as  liable  as  any  of 
those  actually  seized,  and  to  the  infection  of  which,  when 
developed,  he  is  ever  exposed.  In  civil  practice,  on  the 
other  hand,  a  surgeon  is  not  subjected  to  those  predisposing 
and  exciting  causes  of  disease — cold,  want  of  food  and 
clothing,  etc. — which  cause  its  appearance  among  the  mass 
of  the  population,  nor  does  he  remain  exposed  to  its  infection 
longer  than  is  necessary  to  prescribe  for  his  patient.  The 
want  of  libraries  for  study  and  self-improvement  are  also 
drawbacks  to  the  exercise  of  the  profession  in  armies,  of 
which  the  civilian  has  no  experience. 

The  strict  discipline  which  prevails  in  military  hospitals 
gives  the  army  surgeon  some  advantages  over  the  civilian  in 
the  treatment  of  his  cases.  No  interference  from  the  ill- 
judged  kindness  of  relatives,  or  from  the  headstrong  willful- 
ness of  the  patient  himself,  can  occur.  His  opinion  is  a  law 
from  which  there  is  no  appeal,  and  thus  fewer  obstacles  stand 
in  the  way  of  his  giving  a  fair  trial  to  remedies.  He  has, 
also,  the  advantages  so  often  denied  the  civilian,  of  correct- 
ing or  confirming  his  diagnosis  and  treatment  by  after-death 
examination — a  point  of  the  greatest  moment.  He  can,  in 
general,  exercise  his  judgment  also  to  the  fullest  without 
having  his  decision  criticised  by  a  host  of  ignorant  censors, 
and  thus  the  moot  points  in  surgery  can  often  be  determined 
by  him  in  a  manner  not  permissible  in  civil  life. 

The  greater  uniformity  in  age,  constitution,  and  external 
circumstances  that  is  to  be  found  among  patients  in  the 
public  services  than  among  the  mass  of  the  population  who 
enter  civil  hospitals,  makes  conclusions  drawn  from  their 
treatment  more  reliable  for  future  guidance  in  dealing  with 
them,  than  any  statistics  derived  from  civil  practice  can  be 
for  general  purposes. 

But  how  different  are  the  means  of  treating  injury  in  the 
field  and  in  civil  life  !  The  ample  space,  established  routine, 
careful  nursing,  many  comforts  and  appliances  of  a  civil  hos- 
pital contrast  strongly  with  the  temporary  nature,  hurried 


SOLDIERS   AS   PATIENTS.  89 

extemporized  inventions,  and  incomplete  arrangements  of  a 
military  hospital  in  the  field. 

The  influx  of  patients  from  the  works  of  a  besieging  force, 
or  the  shifting  from  place  to  place  of  an  arm}7  during  a  cam- 
paign, makes  the  removal  of  the  sick  to  the  rear  a  necessity. 
Then,  as  this  transference  has  often  to  be  accomplished  by 
means  little  adapted  for  the  purpose,  and  at  a  period  of  the 
treatment  the  worst  fitted  for  its  execution,  the  evil  done  is 
often  irreparable;  so  that  injuries  which  might  be  completely 
cured  in  stationary  hospitals,  have  often  to  be  relieved  by 
amputation,  while  others  whose  treatment  might,  under  more 
favorable  circumstances,  have  afforded  a  fair  prospect  of  suc- 
cess, are  placed  beyond  recovery.  From  this  it  follows  that 
the  military  surgeon  cannot  always  choose  either  his  own 
time  or  circumstances  in  performing  his  operations.  He 
must  be  content  to  do  the  best  he  can  in  the  crisis,  and  thus 
his  experience  has  sometimes  to  be  sacrificed  to  expediency. 
His  operations,  too,  often  differ  widely  from  the  classic  pro- 
cedures of  civil  life.  The  adage,  that  "a  good  anatomist  may 
operate  in  any  way,"  has  often  in  him  its  illustration.  The 
object  being  to  save  as  much  as  possible,  compels  him  to  tax 
his  ingenuity  in  order  to  take  advantage  of  the  eccentric 
manner  in  which  the  ball  has  half  accomplished  the  severance 
of  the  limb,  and  to  seize  his  flaps  here  and  there  where  they 
may  be  got;  and  thus,  though  the  immediate  result  may  not 
appear  so  satisfactory,  the  final  end  is  probably  as  effectively 
secured.  In  the  practice  of  field  surgery,  moreover,  methods 
of  operating  will  often  succeed  which  are  not  adapted  for 
civil  practice.  Thus,  in  the  resection  of  joints  which  come 
to  be  performed  in  the  field,  a  comparatively  small  and  simple 
incision  will  enable  the  operator  to  remove  the  injured  parts, 
while  in  those  cases  in  which  the  operation  is  commonly  per- 
formed in  civil  life,  a  much  larger  and  more  complex  incision 
is  generally  required  in  order  to  permit  of  the  extraction  of 
the  enlarged,  adherent,  unbroken  bone  which  has  to  be  re- 

8* 


90  SURGERY   OP   THE   CRIMEAN   WAR. 

moved,  and  perhaps  to  allow  of  the  excision  of  part  of  the 
articular  cavity  at  the  same  time. 

As  contrasted  with  the  duties  of  the  naval  surgeon,  those 
of  the  military  surgeon  are  much  more  difficult.  His  patients 
are  widely  scattered,  do  not  come  so  soon  under  his  care  when 
injured,  are  subjected  to  greater  hardships,  both  immediately 
after  being  wounded  and  during  treatment,  than  are  the  pa- 
tients of  the  naval  surgeon.  "The  sailor  fights  at  home," 
while  the  unfortunate  soldier  has  often  much  suffering  to  go 
through  before  he  is  admitted  into  hospital. 

The  soldier  as  a  patient  differs  from  the  civilian  in  several 
well-marked  points.  In  some  respects  he  is  a  better  patient, 
and  in  many  respects  he  is  a  much  worse  one.  Some  of  these 
points  of  distinction  should  always  be  borne  in  mind  when 
estimating  the  success  of  surgery  as  practiced  in  the  case  of 
the  one  or  the  other. 

Chosen  when  young  from  the  mass  of  the  population  on 
account  of  his  physical  promise ;  selected  with  care  during 
peace,  with  less  discrimination  during  war,  the  soldier  at 
starting  is  advantageously  contrasted  with  the  majority  of 
the  men  of  his  own  age.  Chosen  without  any  reference  to  his 
moral  character,  he  is  not  uncommonly  depraved  and  profli- 
gate in  his  habits,  and  has  perhaps  enlisted  in  the  reckless- 
ness which  succeeds  to  debauch,  or  as  a  last  resource  to  save 
him  from  penury.  We  have  thus,  not  unfrequently,  two  con- 
ditions meeting  in  the  young  recruit,  both  of  which  bear 
their  own  fruit  in  his  future  history — a  tendency  to  indulge 
in  vices  which  lead  to  disease,  but  a  state  of  health  in  which 
disease  has  not  been  as  yet  established. 

Taken  from  a  domestic  life  in  which  he  had  possibly  every 
liberty  as  to  the  disposal  of  his  time,  the  formation  of  his 
habits,  and  the  pursuit  of  his  amusements,  he  is  at  once 
placed  under  the  rigors  of  a  discipline  which  soon  becomes 
irksome.  He  enjoys  little  leisure,  but  is  harassed  by  his  un- 
accustomed, and,  for  a  time  at  least,  laborious  duties.  Nos- 
talgia succeeds,  and  thus  the  period  of  acclimatization,  as  it 


SOLDIERS   AS   PATIENTS.  91 

may  be  termed,  becomes  an  ordeal  so  trying  as  in  many  in- 
stances to  implant  the  germs  of  disease.  The  prejudicial 
effects  of  this  initiation  will  be  the  more  sure,  if  the  recruit 
be  launched  into  the  real  business  of  a  war  camp  before  his 
constitution  has  had  time  to  accommodate  itself  to  the  new 
condition  of  things  in  which  it  is  for  the  future  to  exist. 
But  if  the  young  soldier  get  over  this  novitiate,  then  his 
physical  condition,  during  a  time  of  peace  at  least,  is  un- 
doubtedly favorable  as  contrasted  with  his  fellow  in  civil  life. 
His  food,  which  js  well  adapted  for  his  use,  is  provided  for 
him  regularly.  He  is  systematically  exercised.  His  hours 
of  labor  and  repose  are  carefully  arranged,  and  he  is  at  all 
times  liberally  supplied  with  fresh  air.  The  civilian,  on  the 
other  hand,  though  not  subjected  to  the  rough  change  of  ex- 
istence which  the  soldier  has  to  undergo,  is  greatly  less  regu- 
lar in  his  mode  of  life.  He  lives  frequently  in  close  streets 
and  airless  dwellings.  His  food  is  irregular,  varying  with 
the  profits  of  his  labor.  He  indulges  without  restraint  when 
he  can  aiford  it,  and  has  to  submit  to  privation  afterward  to 
compensate  for  the  excess. 

In  war,  again,  the  soldier  loses  many  of  his  advantages 
over  the  civilian.  The  external  circumstances  which  predis- 
pose to  or  generate  disease  are  more  numerous  and  vastly 
more  potent  in  his  case  than  they  ever  are  in  civil  life.  The 
exposure,  the  bad  and  irregular  food,  the  deficient  shelter, 
the  excessive  fatigue,  the  unnatural  excitement  or  depression 
of  victory  or  defeat,  all  tend  to  reduce  him  as  much  below 
as  he  was  formerly  above  the  civilian  in  the  scale  of  health. 
He  has,  amid  "the  irregularities  of  war,"  opportunities  for 
licentiousness  of  which  he  is  not  slow  to  take  advantage,  and 
his  unquiet  and  exciting  life  is  but  too  apt  to  occasion  that 
"  debility  of  excess"  which  conceals  a  constitution  weak  to 
resist  injury,  under  an  outward  appearance  of  strength  and 
vigor.  Thus  it  is,  that  as  in  civil  life  different  trades  pro- 
duce different  diseases,  so  a  soldier's  life,  both  in  peace  and 


92  SURGERY   OF   THE   CRIMEAN    WAR. 

war,  begets  its  own  diseases,  and  secures  exemption  from 
others  to  which  civilians  are  liable. 

Morally  as  well  as  physically  the  sick  soldier  differs  from 
the  inmate  of  a  civil  hospital.  If  wounded,  he  received  his 
injury  in  the  discharge  of  his  duty  ;  if  sick,  in  the  fulfillment 
of  praiseworthy  service.  His  "  honorable  scars"  recognize 
none  of  those  causes  referable  to  misconduct  or  stupid 
thoughtlessness,  which  so  frequently  make  the  civilian  the 
inmate  of  a  hospital.  He  has  no  fear  like  the  civilian  for 
the  future,  if  incapacitated  for  further  service,  as  he  knows 
that  his  misfortune  will  entitle  him  to  sustenance  for  the 
time  to  come,  and  that  his  country  will  regard  him  with 
gratitude. 

When  struck  down  by  sickness,  the  soldier  is,  however, 
thrown  more  upon  himself  than  the  civilian,  and  this  isola- 
tion must  in  his  case  act  prejudicially  on  his  recovery.  He 
has  no  visits  from  sympathizing  friends,  as  he  lies  on  a  sick 
bed,  far  from  home,  amid  the  selfish  hardness  of  a  camp. 
He  is  soon  separated  from  his  comrades,  and  placed  among 
strangers  gathered  like  himself  from  the  accidents  of  the 
field,  and  he  finds  himself  in  circumstances  where  he  has  little 
to  cheer  but  much  to  depress  him.  In  the  injuries  to  which 
he  is  exposed  in  war,  he  is  more  hardly  dealt  with  than  the 
civilian.  The  accidents  which  befall  him  equal  in  their  se- 
verity the  most  terrible  which  occur  in  civil  life.  The  effects 
produced  by  the  massive  round  shot  or  ponderous  shell  are 
very  like  the  crushing  and  tearing  of  machinery  impelled  by 
the  resistless  steam ;  so  that,  among  the  many  assimilating 
effects  of  our  railways  and  manufactories,  one  will  evidently 
be,  in  course  of  time,  the  bringing  of  the  surgery  in  civil  hos- 
pitals more  and  more  into  conformity  with  that  of  war. 

But,  besides  all  that  I  have  said  as  to  those  matters  in 
which  military  and  civil  surgery  are  similar  or  disagree,  and 
as  to  the  contrast  which  exists  on  some  points  between  the 
patients  falling  to  be  treated  in  either  case,  there  are  yet 
some  circumstances  in  the  late  war  to  which  I  must  allude, 


PECULIARITY   OP   WOUNDS   SEEN   IN   THE   CRIMEA.         93 

as  they  are  peculiar  in  themselves,  and  have  an  especial 
bearing  on  its  surgical  annals. 

A  siege  differs  considerably  from  ordinary  campaign  work 
both  in  the  description  and  mortality  of  the  wounds  to  which 
it  exposes  the  soldier.  The  close  proximity  of  the  opposed 
batteries,  the  steady  and  deadly  aim  which  can  be  obtained 
by  the  riflemen,  the  range  so  soon  ascertained  for  cannon 
and  mortar,  the  guns  so  carefully  and  accurately  worked 
from  the  absence  of  hurry  and  from  the  daily  practice  of  the 
gunners,  all  contribute  to  render  the  proportion  of  casual- 
ties higher  and  their  severity  greater  in  sieges  than  the  in- 
juries which  attend  a  campaign  in  the  field.  Wounds  of  the 
upper  half  of  the  body  may  be  expected  to  be  more  common 
in  a  siege,  from  the  lower  parts  being  protected  by  the  works, 
and  shell  wounds  must  also  be  of  more  frequent  occurrence, 
from  the  larger  employment  of  mortars  in  attacking  or  de- 
fending a  city.*  The  sudden  sorties  from  the  beleaguered 
garrison,  the  long  and  constant  exposure  to  the  enemy's  fire 
while  forming  and  guarding  the  trenches,  all  conduce  to 
swell  the  number  of  those  injured. 

The  health  of  the  troops,  moreover,  does  not  maintain  so 
high  a  standard  when  they  are  stationary,  and  want  the 
wholesome  animation  which  results  from  the  change  and 
stirring  incidents  of  a  moving  campaign ;  whence  it  follows 
that,  on  becoming  inmates  of  the  hospital,  they  are  not  so 
fit  to  stand  active  treatment,  nor  are  they  so  "  lively  at  re- 
covery." 

However,  there  is  one  advantage  which  a  siege  has  over 
a  campaign  in  the  field,  and  it  is  a  considerable  one.  The 
hospitals,  being  more  stationary,  can  be  better  arranged,  and 

*  In  the  civil  insurrections  of  Paris,  they  observed  the  greater  fre- 
quency of  wounds  in  the  upper  part  of  the  body,  and  the  conse- 
quently greater  mortality  among  the  revolted,  who  fired  from  windows 
aud  behind  barricades,  than  among  the  soldiers,  who  occupied  the 
open  street. 


94  SURGERY   OP   THE   CRIMEAN    WAR. 

placed  so  near  the  scene  of  conflict  that  the  injured  ma}7  be 
more  quickly  succored. 

During  the  late  war,  our  army  had  not  only  to  go  through 
the  ordeal  of  great  battles,  but  the  prosecution  of  a  siege 
unequaled  for  its  difficulties  in  the  history  of  war — a  siege 
in  which  every  obstacle  and  every  trial  was  enhanced  by  the 
stubborn  resolution  of  a  brave  enemy  and  the  frailty  of  our 
own  military  preparation.  The  sorties  were  on  a  scale  so 
gigantic,  and  pushed  so  resolutely,  as  to  occasion  effects 
little  inferior  to  those  of  a  pitched  battle  ;  and  the  extraor- 
dinary length  and  active  prosecution  of  the  siege  caused  re- 
sults resembling  those  of  a  constant  battle  several  months  in 
duration.  A  few  general  engagements,  and  the  casualties 
of  outpost  service,  make  up  the  accidents  of  an  ordinary 
campaign  ;  but  with  us,  day  after  day,  and  night  after  night, 
kept  up  a  constant  strain,  which  was  more  exhausting  to  the 
strength  of  the  army  than  any  other  sort  of  warfare  could 
have  been. 

The  majority  of  the  recruits  who  joined  the  army  early 
in  1855,  and  who  supplied  many  of  the  wounded  of  that 
year,  were  far  from  being  well  chosen.  They  were  selected 
under  a  pressure,  and  were  the  contributions  of  a  country 
where  the  drag-net  of  the  conscription  is  not  used  to  inclose 
the  good  as  well  as  the  bad,  and  where  a  soldier's  life  is  not 
in  any  honor  or  favor  with  the  generality  of  the  people. 
Many  of  them  were  raw  boys,  ill  conditioned,  below  the 
standard  age,  undeveloped  in  body,  unconfirmed  in  constitu- 
tion, and  hence  without  stamina  or  powers  of  endurance. 
Often  selected  on  account  of  their  precocious  growth,  at 
once  launched  into  the  turmoil,  unwonted  labor,  and  hard- 
ship of  a  siege  ill  which  the  strength  of  full-grown  men  soon 
failed,  they  were  very  quickly  "  used  up."  Cholera  or  fever 
speedily  seized  them,  overtaxed  as  they  were  in  work,  and 
unaccustomed  to  either  the  food  or  the  exposure  which  fell 
to  them.  The  hospitals  became  filled  with  such  unpromis- 
ing patients,  whose  "  wizened"  look  of  premature  age  was 


RECRUITS.  95 

remarked  by  the  most  casual  observer.  If  these  unfortunate 
boys  were  severely  wounded,  they  almost  invariably  died,  as 
their  weakly  constitutions  and  overstrained  powers  could  not 
withstand  "the  ordeal  of  recovery."  To  them  Hunter's 
saying  applied  with  peculiar  force,  that  "  their  condition  of 
health  did  not  bear  disease."  If  they  survived  the  first 
effects  of  their  injury,  their  convalescence  was  painfully  pro- 
longed, and  the  least  imprudence  produced  a  relapse.  Their 
ailments  were  seldom  acute — their  life-power  was  unequal  to 
its  production ;  their  nervous  systems  were  shattered ;  and 
that  undefined  but  most  fatal  disease  known  as  the  "  mal  des 
tranches"  was  soon  set  up.  Depletory  measures  had  soon 
to  be  abandoned,  and  a  more  rational  treatment,  founded  on 
special  symptoms  and  the  observed  effects  of  remedies,  sub- 
stituted for  the  conventional  medication. 

Again,  several  of  the  regiments  which  suffered  most  in 
many  of  the  assaults,  and  which  consequently  contributed 
the  greater  number  of  the  operative  cases,  were,  either 
wholly  or  in  part,  composed  of  men  who  had  just  returned 
from  prolonged  service  in  India.  Men  so  circumstanced 
were  but  ill  calculated  to  undergo  the  rigors  of  a  Crimean 
winter,  or  the  hard  work  of  the  trenches,  or  yet  the  great 
trial  of  a  capital  operation. 

There  was  yet  another  element  which  demands  attention, 
when  estimating  the  surgical  records  of  the  war.  I  refer  to 
the  use  of  the  new  rifle,  with  its  conical  ball.  The  rifle  used 
by  the  Russians  was  little  inferior  in  range  or  force  to  our 
Minie,  while  its  conical,  deep-cupped  ball  was  much  heavier. 
The  great  variety  in  form  and  weight  which  the  balls  used 
by  the  belligerents  presented  will  be  seen  by  reference  to  the 
table  in  the  appendix,  (E,)  where  the  particular  description 
and  weight  of  each  are  given.  The  greater  precision  in 
aim,  the  immensely  increased  range,  the  peculiar  shape,  great 
force,  and  unwonted  motion  imparted  by  the  new  rifles  to 
their  conical  balls  have  introduced  into  the  prognosis  of 
gunshot  wounds  an  element  of  the  utmost  importance.  I 


96  SURGERY  OF  THE  CRIMEAN  WAR. 

am  not  prepared  to  say  whether  the  great  destruction  of  the 
soft  and  hard  tissues  which  these  balls  occasion  results  from 
their  wedgelike  shape,  immense  force  and  velocity,  or  the 
revolving  motion,  or  from  a  combination  of  all  these  causes 
together ;  but  of  one  thing  I  am  convinced,  that  their  use 
has  changed  the  bearing  of  many  points  which  fall  to  be 
considered  by  the  surgeon  in  the  field.  The  severity  of  the 
primary  action  on  the  part  struck,  and  especially  the  aggra- 
vated evils  which  follow  their  wounds,  combined  to  exercise 
a  most  prejudicial  influence  on  the  surgery  of  the  war,  to 
which  due  weight  has  never  been  given.  Immense  commi- 
nution of  bone  has  been  their  most  prominent  effect.  The 
amount  of  laceration  of  the  soft  parts  seems  to  depend  on 
the  distance  at  which  the  missile  is  fired. 

The  wide-spread  destruction  of  the  bone  often  renders 
consolidation  impossible,  so  that  amputation  has  more  fre- 
quently to  be  had  recourse  to,  and  the  distance  from  the 
trunk  at  which  that  operation  has  to  be  performed  being 
diminished  by  the  same  causes,  the  resulting  mortality  has 
been  greatly  increased.  All  who  compared  the  dead  of  this 
with  those  of  former  wars,  especially  of  Indian  battles,  were 
painfully  struck  with  the  greater  disfigurement  of  the  corpse 
caused  by  the  conical  than  by  any  other  species  of  ball. 

But  besides  the  more  destructive  nature  of  the  small  arms 
employed,  cannons  and  mortars  were  used  on  both  sides,  of 
a  caliber  and  range  never  before  tried  in  any  war.  When 
Pare  thought  the  cannon  of  his  day  so  enormous  and  de- 
structive, what  can  we  say  of  those  huge  sea-service  mor- 
tars and  immense  cannon  used  to  defend  and  attack  Sebas- 
topol,  compared  with  which  those  of  the  last  century  are  as 
toys  I*  The  fragments  of  our  modern  shells  must  be  as 

*  "Truly,"  says  Pare,  "when  I  speak  of  the  machines  which  the 
ancients  used  for  assaulting  men  in  combats  and  encounters,  it 
appears  to  me  as  if  I  spoke  of  infants'  toys  in  comparison  with 
these,  which,  to  speak  literally,  surpass  in  figure  and  cruelty  the 
things  which  they  thought  the  most  cruel." 


THE    NEW    FIRE-ARMS.  97 

weighty  as  the  whole  projectile  known  to  our  forefathers, 
and  the  grape  which  was  so  freely  used  in  the  East  were 
half  as  large  as  the  round  shot  fired  from  the  field  guns  in 
the  Peninsula.  With  us,  every  refinement  in  the  art  of 
destruction  was  liberally  practiced,  so  that  "  Part  de  tuer  les 
hommes  avec  methode,  et  gloire,"  was,  unhappily,  never  car- 
ried nearer  perfection,  though  we  may  comfort  ourselves  with 
the  reflection  of  Percy,  that  this  very  perfection,  "  nous  a 
donne  la  meme  tache  et  la  meme  recompense  dans  Part  de 
les  conserver."  "  Les  circonstances,"  says  Briot,  "  qui  con- 
tribuent  le  plus  a  la  destruction  des  hommes  sont  aussi  celles 
qui  font  decouvrir  et  developpent  plus  de  moyens  propres  a 
leur  conservation." 

Finally,  if  in  war  the  surgeon  sees  much  which  is  terrible, 
much  which  taxes  his  feelings  of  humanity,  and  his  regret 
at  the  feebleness  of  his  art,  he  has  also  the  comforting  con- 
viction that  nowhere  is  his  beneficent  mission  so  felt,  no- 
where is  the  saving  power  of  his  profession  so  fully  exer- 
cised;  so  true  is  it  that  "chirurgery  triumphs  in  armies 
and  in  sieges.  'Tis  there  that  its  empire  is  owned;  'tis 
there  that  its  effects,  and  not  words,  express  its  eulogium."* 

*  Dionis,  quoted  by  Sir  George  Ballingall. 


CHAPTER  Y. 

THE  "PECULIARITIES"  OF  GUNSHOT  WOUNDS,  AND  THEIR 

GENERAL  TREATMENT. 

IN  saying  that  "  there  is  a  peculiarity,  but  no  mystery, 
in  gunshot  wounds,"  John  Bell  has  expressed  the  change 
of  opinion  which  late  times  have  brought  about  with  regard 
to  the  nature  of  these  injuries.  It  was  the  mysterious  char- 
acter ascribed  by  the  old  surgeons  to  wounds  from  so  "  devil- 
ish an  engine"  as  a  gun,  which  so  long  surrounded  them 
with  dread,  and  made  incantations  and  charms  the  favorite 
resource  in  their  treatment.  The  new  philosophy  has  dis- 
pelled the  mystery,  but  left  us  still  to  study  the  eccentricities 
which  so  often  mark  these  injuries.  The  contused  appear- 
ance and  unavoidable  sloughing  of  the  walls  of  the  ball's 
track,  the  little-suspected  but  serious  destruction  of  deep 
parts,  and  the  grave  consequences  which  may  ensue  from 
such  a  wound  appear  to  have  been  the  circumstances  that 
suggested  the  envenomed  nature  of  gunpowder,  and  the 
cautery-like  action  of  its  projected  ball,  as  well  as  the  idea 
which  prevailed,  that  in  order  to  get  quit  of  the  injurious 
influences  thus  exerted  on  the  wound,  it  was  necessary  to 
pour  into  it  burning  oil,  or  curious  tinctures  concocted  from 
the  most  opposite  and  absurd  ingredients,  or  to  smear  the 
part  with  nauseous  grease  and  "charmed  salves." 

The  description  of  the  sensation  caused  by  a  gunshot 
wound  in  a  fleshy  part,  usually  given  by  the  sufferer,  is,  that 
it  resembles  the  effect  of  a  smart  blow  from  a  supple  cane. 
Some,  however,  feel  as  if  a  red-hot  wire  were  passed 
through  the  part.  The  fracturing  or  splintering  of  a  bone 
is  always  more  painful  than  a  flesh  wound,  and  if  a  joint  or 
(98) 


SENSATIONS   CAUSED   BY  A  GUNSHOT   WOUND.  99 

larger  cavity  be  penetrated,  the  pain  is  still  more  acute,  and 
the  shock  still  greater — in  most  cases  proportioned  to  the 
vitality  of  the  part  injured. 

It  is  a  very  remarkable,  though  universally  known  fact, 
that  when  the  mind  is  greatly  engrossed  by  external  objects 
— excited  "  'mid  the  current  of  the  heady  fight," — severe 
wounds  may  be  received  without  any  consciousness  on  the 
part  of  the  receiver.  Whether  the  sensation  may  be  so 
very  slight  as  to  be  immediately  obliterated  by  the  tide  of 
strong  passions  rushing  through  the  mind  of  the  combatant, 
or  whether  a  reflex  act  of  the  mind  be  necessary  for  receiv- 
ing a  sensation — in  common  words,  for  perceiving  the  state 
of  its  companion,  the  body — I  shall  riot  attempt  to  discuss. 
But  all  military  surgeons  will  confirm  the  statement  of  Hen- 
nen,  when  he  says  that  "  some  men  will  have  a  limb  carried 
off,  or  shattered  to  pieces  by  a  cannon-ball,  without  exhibit- 
ing the  slightest  signs  of  mental  or  corporeal  agitation — 
nay,  without  being  conscious  of  it."  I  myself  have  known 
an  officer  who  had  both  legs  carried  away,  and  who  said 
that  it  was  only  when  he  attempted  to  rise,  he  became  aware 
of  the  injury  he  had  received;  and  very  many  who  had  suf- 
fered slighter  wounds,  have  said  that  the  trickling  of  blood 
along  the  skin  was  what  first  called  their  attention  to  their 
state.* 


*  This  is  a  very  curious  and  interesting  subject  to  the  physiolo- 
gist, to  all  who  study  the  marvelous  interdependence  of  mind  and 
body.  What  the  exact  province  of  each  is,  we  are  not  in  circum- 
stances to  determine,  as  we  see  all  their  operations  carried  on  con- 
jointly ;  but  every  one  is  aware  that  pain  and  sickness  are  greatly 
aggravated  by  the  constant  contemplation  of  them,  and  lightened  by 
the  mind  looking  elsewhere.  The  American  Indians,  whose  stoicism 
has  been  so  frequently  extolled  in  song  and  story,  were  well  aware 
of  this  last-mentioned  law,  for  during  the  infliction  of  the  most  hor- 
rible tortures  by  the  enemy,  they  sung  the  war-song  of  their  tribe, 
and  recounted  the  most  glorious  victories  over  their  bitterest  foes. 
Whether  from  philosophy  or  instinct,  they  directed  the  mind  to  the 


100  SURGERY   OF   THE    CRIMEAN    WAR. 

The  collapse  and  mental  trepidation  which  frequently 
follow  the  infliction  of  a  mortal  wound  in  the  trunk  are,  in 
many  cases,  most  appalling.  But  although  the  presence  or 
absence  of  this  severe  constitutional  effect  is  useful  as  a 
diagnostic  indication  of  the  gravity  of  the  injury,  it  is  not 
entirely  to  be  depended  on,  for  the  terror  and  amount  of 
shock  frequently  depend  as  much  on  the  nerve  and  frame  of 
the  sufferer  as  on  the  severity  of  the  wound.  The  different 
effects  produced  on  different  persons  by  wounds  in  every 
respect  alike  are  obvious  to  every  one  who  has  seen  war, 
and  call  for  the  exercise  of  a  most  discriminating  judgment 
on  the  part  of  the  surgeon.  Then,  the  period  of  collapse, 
which  will,  to  some  degree,  occur  in  every  case  of  a  severe 
wound,  varies  greatly,  which  must  determine  whether  imme- 
diate amputation  be  necessary,  or  whether  it  would  be  safe 
to  delay  it.  The  only  other  remark  we  make  on  this  sub- 
ject is,  that  the  "commotion"  succeeding  gunshot  wounds  is 
greater  when  the  lower  extremities  are  injured  than  when 
the  arms  suffer;  and  this  is  more  especially  seen  if  the  per- 
son be  in  an  erect  position  when  the  injury  is  inflicted; 
which  observation  is  consistent  with  the  remark  made  by 
Chevalier,  that  the  shock  is  always  greater  when  the  ball 
strikes  a  muscle  in  action  than  when  it  impinges  against  one 
which  is  relaxed. 

The  destruction  inflicted  by  a  ball  depends  on  the  dis- 

most  exciting  and  attractive  topics,  those  best  fitted  to  engross  and 
absorb  it,  and  to  prevent  it  from  looking  at  the  wounds  inflicted  on 
the  body,  or  listening  to  the  taunts  directed  against  the  mind;  and 
thus,  if  they  did  not  actually  prevent  or  nullify  pain,  they  greatly 
lessened  its  intensity.  We  doubt  not  that  the  "noble  army  of  mar- 
tyrs',' were  often,  through  the  same  general  law,  enabled  to  rejoice 
even  amid  the  flames,  the  mind  being  in  a  great  degree  absorbed  by 
the  contemplation  of  the  glory  awaiting  them,  revealed  to  them,  as 
to  the  protomartyr,  a  brightness  which  the  inner  eye  could  behold, 
and  thus  they  were  almost 

"laid  asleep 
In  body,  and  became  a  living  soul." 


GUNSHOT    WOUNDS   AND    TFIjETR   TREATMENT.  101* 

tance  at  which  it  is  fired,  the  direction  of  its  flight,  its  shape 
and  velocity,  as  well  as  on  the  nature  of  the  part  struck. 
If  fragments  of  metal  are  fired,  as  sometimes  happened 
during  the  sieges  of  the  Peninsula,  as  well  as  in  the  civil 
ententes  of  Paris,  and  of  which  we  had  some  experience  in 
the  Crimea  also,  a  very  lacerated,  irregular,  and  dangerous 
wound  may  be  caused.*  A  ball  passing  at  great  speed  over 
the  surface  of  a  limb  may  occasion  a  wound  similar  to  that 
made  by  a  knife.  But  this  action  of  a  ball  is  rare.f 

The  great  velocity,  peculiar  shape,  and  motion  of  the 
conical  ball  give  to  its  wounds  a  character  considerably  dif- 
ferent from  those  which  is  present  in  wounds  caused  by  a 
round  musket-ball.  If  fired  at  short  range,  and  if  it  strike 
a  fleshy  part,  the  conical  ball  produces,  I  think,  less  lacera- 
tion of  the  soft  parts  than  the  old  ball ;  but  if  the  range  be 
great,  and  the  part  struck  bony,  with  little  covering  of  flesh, 
as  in  the  case  of  the  hand  or  foot,  then  the  tearing,  espe- 
cially at  the  place  of  exit,  is  greatly  more  marked. 

I  have  not  been  able  to  satisfy  myself  in  all  cases,  so 
clearly  as  the  description  of  authors  would  lead  me  to  sup- 
pose I  could,  as  to  the  characteristics  which  distinguish  the 
wound  of  entrance  from  that  of  exit.  That  the  former  is 
more  regular  and  less  discolored  than  the  latter,  is  true  in 
many  cases,  but  that  the  lips  of  one  wound  are  inverted, 

*  Hutin  relates  a  case  which  occurred  at  the  siege  of  Constantina, 
where  a  nail  was  found  fairly  driven  into  the  femoral  artery;  and 
in  the  Burmese  war,  links  of  iron  cable  were  fired  by  (he  enemy 
from  their  cannon.  Bullets,  united  together  by  wire  so  as  to  resem- 
ble "bar-shot,"  were  at  times  used  by  the  Russians  in  the  Crimea, 
and  caused  very  irregular  wounds. 

f  This,  which  is,  I  believe,  the  true  state  of  the  question,  is  oppose'], 
however,  to  Hunter's  remark:  "In  this  case  (a  hall  passing  with 
velocity)  a  slough  will  be  produced;  but  if  it,  should  pass  with  little 
velocity,  then  there  will  be  less  sloughing,  and  the  parts  will,  in 
s  >im>  degree,  heal  by  the  first  intention,  similar  to  those  made  by  a 
cutting  instrument." — Hunter's  Works,  by  Palmer,  vol.  Hi.  p.  ;">•"> '.I. 

0* 


'02  SURGKR'Y    OF    THE    CRIMEAN    WAR. 

while  those  of  the  other  are  everted,  has  seldom  been  clearly 
marked  to  my  observation.  If  the  speed  of  the  ball  be 
great,  and  no  bone  have  been  struck,  then  there  is  little  dif- 
ference in  either  the  size  or  discoloration  of  the  wounds ; 
but  if  the  flight  of  the  projectile  be  so  far  spent  as  to  be 
retarded  by  contact  with  the  body,  especially  if  it  have  en- 
countered a  bone  or  a  strong  aponeurosis,  so  that  its  speed 
is  considerably  diminished  before  it  passes  out  of  the  body, 
then  the  wound  of  exit  will  considerably  exceed  in  size  that 
of  entrance.  This  is  especially  true  of  conical  balls.  If, 
on  the  contrary,  the  ball  be  fired  close  at  hand,  so  that  its 
speed  is  not  sensibly  diminished  by  its  passage  through  a 
limb,  then  the  difference  of  size  will  be  very  small,  and  may 
even  be  in  favor  of  the  wound  of  entrance,  as  I  had  twice 
an  opportunity  of  observing. 

The  usual  action  of  a  ball  in  proportioning  the  size  of  the 
two  orifices  is  easily  understood,  when  we  consider  that  the 
part  of  entrance  is  supported  by  the  whole  thickness  of  the 
limb,  while  that  of  escape  is  quite  unsustained,  and  there- 
fore the  more  liable  to  be  torn.  Huguier  has  shown  that 
the  loss  of  substance  which  occurs  at  the  place  of  entrance, 
and  the  flap-like  tearing  which  takes  place  at  the  orifice  of 
exit,  form  the  best  marks  of  recognition  we  possess,  and  that 
these  characters  can  always  be  made  out  by  examination  of 
the  clothes  or  accoutrements  traversed  in  cases  in  which  the 
supervention  of  inflammation  has  effaced  them  from  the 
wound  itself.  The  introduction  but  non-escape  of  a  for- 
eign body,  as  a  piece  of  the  breast-plate,  belt,  buckle,  or  part 
of  the  musket,  etc.,  along  with  the  ball,  which  alone  passes 
out,  or  the  flattening  of  the  ball  against  a  bone  within,  and 
its  diameter  being  thus  increased  before  it  escapes,  will  all 
contribute  to  vary  the  relative  characters  of  the  orifices  of 
the  wound.* 


*  In  Arncl's  experiments,  given  in  the  Journal  Univer.  de  Med.  for 
1830,  it  is  shown  that  a  ball,  fired  against  a  number  of  planks  firmly 


GUNSHOT    WOUNDS   AND   THEIR   TREATMENT.  103 

To  the  military  surgeon,  it  is  often  of  consequence  to  be 
able  to  conclude  whether  the  two  apertures  in  his  patient's 
limb  have  been  occasioned  by  one  ball,  which  is  thus  seen  to 
have  passed  out,  or  by  two  balls  still  imbedded  in  ihe  limb, 
and  to  the  medico-legal  jurist,  the  knowledge  of  the  marks 
which  characterize  the  two  wounds  is  of  much  moment.* 

The  action  of  a  ball  on  the  different  tissues  of  the  body 
may  be,  in  a  great  measure,  inferred  from  a  consideration  of 
the  shape  of  the  projectile,  and  the  nature  of  the  part  struck. 
It  carries  away,  as  I  before  remarked,  a  piece  of  the  skin  at 
the  place  of  entrance,  and  rends  it  where  it  escapes.  The 
small  plug  of  integument  which  is  carried  into  the  wound, 
Huguier  tells  us,  can  often  be  discovered  there. f 

The  contusion  which  a  ball  causes  in  traversing  muscle 


bound  together,  causes  a  series  of  holes  progressively  increasing  in 
size,  so  that  a  cone  is  formed  by  their  union,  whose  base  is  repre- 
sented by  the  last  exit  hole.  M.  Devergie's  experiments  on  the  same 
point,  given  in  his  communication  to  the  Academy,  go  to  prove  this 
also.  Velpeau  and  others  have  objected,  but  without  good  grounds, 
to  the  deductions  drawn  from  the  experiments  being  applied  to  the 
question. 

*  Between  the  opposite  views  held  by  Blandin  and  Dupuytren,  the 
opinions  of  military  surgeons  and  medical  jurists  have  oscillated, 
evidently  from  the  fact  that  no  constant  relations  exist  between  the 
entrance  and  exit  wounds.  Velpeau,  holding  a  middle  view,  con- 
cludes, with  truth,  "Dupuytren  is  wrong,  and  his  antagonist  is  not 
right."  The  distance  at  which  the  gun  is  fired  has  most  to  do  in 
determining  their  character,  according  to  Devergie,  who  has  himself, 
however,  recorded  a  case  which  proves  that  the  wound  of  entrance 
may  be  the  larger,  even  when  the  gun  is  fired  at  a  distance.  Begin 
has  given  us  the  following  valuable  observation,  with  regard  to  the 
resulting  cicatrixes.  That  of  entrance,  he  says,  is  generally  white, 
depressed,  and  often  adherent  to  the  underlying  parts,  while  that  of 
exit  is  only  a  sort  of  irregular  spot,  which  does  not  adhere  to  the 
parts  below,  and  is  sometimes  PO  indistinct  as  to  be  concealed  in  the 
folds  of  the  skin.  This  difference  he  explains  by  the  loss  of  sub- 
stance sustained  at  the  point  of  entrance. 

f  John  Hunter  speaks  also  of  this  piece  of  detached  integument. 


104  SURGERY    OF   THE   CRIMEAN    WAR. 

gives  rise  to  one  marked  characteristic  of  gunshot  wounds 
— their  healing  only  by  suppuration  and  granulation.  Oc- 
casionally an  exception  occurs  to  this  rule.  Thus,  I  have 
seen  a  case  in  which  a  superficial  wound  of  the  gastrone- 
mius  was  said  to  have  healed  without  suppuration  by  the 
fifth  day,  and  in  the  records  of  a  Sepoy  regiment  in  India, 
I  find  mention  of  even  a  deeper  gunshot  wound  of  the  del- 
toid healing  in  the  same  way  by  first  intention. 

Dr.  Stewart,  staff  assistant  surgeon,  reports*  a  case  of  a 
similar  union,  as  having  been  observed  by  him  during  the 
Kaffre  war.  A  Fingo  received  a  pretty  severe  gunshot 
wound  of  the  muscles  of  the  back,  and  union  without  sup- 
puration took  place.  Two  things  are  necessary  to  produce 
such  a  happy  result:  1st,  a  most  healthy  and  temperate 
patient;  and,  2d,  the  rapid  flight  of  the  ball. 

It  is  curious  to  notice  how  large  a  body  may  enter  through 
a  muscle,  and  hide  itself  without  producing  any  great  wound. 
Thus,  I  saw  a  case  at  Scutari,  in  which  a  piece  of  shell, 
weighing  nearly  three  pounds,  was  extracted  from  the  hip 
of  a  man  wounded  at  the  Alma,  which  had  been  overlooked 
for  a  couple  of  months,  and  to  which  but  a  small  opening 
led.  Larrey  gives  a  case  in  which  a  ball,  weighing  five 
pounds,  was  extracted  by  him  from  the  thigh  of  a  soldier. 
The  presence  of  so  large  a  body  had  not  been  detected  by 
the  surgeon  in  charge,  and  the  patient  suffered  no  inconve- 
nience from  it  beyond  a  feeling  of  weight  in  the  limb.  Pail- 
lard  mentions  having  heard  M.  Begin  recount  a  case  in 
which  a  ball  of  nine  pounds  so  buried  itself  for  a  time. 
Hennen,  too,  mentions  a  case  as  having  occurred  at  Sering- 
apatam,  in  which  a  spent  twelve-pound  shot  buried  itself  in 
the  thigh  of  an  officer,  and  "so  little  appearance  was  there 
of  a  body  of  such  bulk,  that  he  was  brought  to  the  camp, 
where  he  soon  expired,  without  any  suspicion  of  the  presence 
of  the  ball  till  it  was  discovered  on  examination."  It  is 

*  Unpublished  Records  of  Medical  Department. 


GUNSHOT    WOUNDS   AND   THEIR   TREATMENT.  105 

more  easy  to  understand  how  a  large  fragment  of  shell 
should  so  conceal  itself  than  a  round  shot,  as,  if  its  long 
diameter  corresponded  with  the  run  of  the  fibers  of  the 
superficial  muscles,  and  especially  if  the  muscle  was  relaxed 
at  the  time  of  contact,  then  a  large  piece  might  enter  a  mus- 
cular limb  without  causing  an  amount  of  injury  proportioned 
to  the  size  of  the  body  introduced.  Such  an  instance  oc- 
curred in  the  Crimea  to  a  French  soldier,  of  whose  case 
Bandens  has  given  an  account.  A  fragment  of  shell,  weigh- 
ing 2  kilog.  150  grammes,  so  completely  buried  itself  in  the 
'thigh  as  almost  to  be  invisible.  The  elasticity  of  the  soft 
parts  doubtless  assist  in  closing  the  opening  by  which  such  a 
mass  entered. 

Baudens  has  made  an  observation  which  I  am  not  aware 
has  been  confirmed  by  any  other,  viz.,  that  when  the  ball  is 
cut  out  from  among  the  muscles,  however  early  it  may  be 
accomplished,  it  has  a  cellular  envelope  round  it,  which  he 
calls  "kyste  primatif,"  as  contrasted  with  the  "kyste  defini- 
tif,"  which  forms  its  sac  when  it  has  been  long  inclosed  in 
the  tissues. 

Muscles  which  have  been  severely  injured  by  ball  are  very 
apt  to  become  contracted  during  cure,  if  precautions  are  not 
taken  to  prevent  it.  Of  this  most  disagreeable  result  I  have 
seen  a  good  many  cases  in  the  East. 

On  tendons  a  ball  may  cause  little  or  no  injury,  especially 
if  they  be  relaxed  at  the  moment  they  are  struck.  Their 
toughness,  elasticity,  form,  and  mobility  all  help  in  protect- 
ing them  from  being  cut  across,  or  pierced.  A  round  ball 
is  often  deflected  by  a  strong  aponeurosis  like  the  "fascia 
lata,"  particularly  if  it  strike  at  an  angle  to  the  surface,  and 
at  a  period  of  its  flight  when  the  force  is  somewhat  expended. 
A  conical  ball,  however,  is  seldom  so  turned. 

It  is  on  bone  that  the  destructive  effects  of  a  ball  become 
most  evident.  (1)  When  its  line  of  flight  is  very  oblique, 
and  it  is  a  flat  bone  against  which  it  strikes,  then  it  may  be 
thrown  off,  causing  no  other  damage  than  depriving  the  bone 


106  BURGER  5T    OF    THE    CRIMEAN    WAR. 

of  its  periosteum.  When  this  occurs  in  the  case  of  bones 
of  the  head,  much  danger  may  subsequently  ensue,  as  will 
afterward  be  shown.  Contused  wounds  of  the  long  bones, 
though  seemingly  of  little  moment  at  first,  are  sometimes 
very  serious  in  their  results,  not  only  from  the  separation  of 
the  periosteum,  and  subsequent  disease  of  the  bone  arising 
from  that  source,  but  also  from  inflammation  being  set  up  in 
the  medullary  canal.  (2)  A  round  ball  may  be  flattened 
against  the  shaft  of  a  long  bone,  without  causing  any  subse- 
quent harm.  This  was  often  seen  in  India,  where  the  match- 
lock is  used.  (3)  It  may  turn  round  a  bone  without  break- 
ing it.  Thus,  Chevalier  records  a  case  in  which  a  ball, 
entering  at  the  lower  part  of  the  thigh,  passed  spirally 
round  the  bone  to  the  top  of  the  limb,  "  comprehending 
nearly  the  whole  length  of  the  bone  in  one  circumvolution." 
(4)  A  round  ball,  as  is  well  known,  may  notch  or  partly 
perforate  a  long  bone  without  causing  fracture,  and  pass  off, 
or  remain  in  the  medullary  cavity,  having  passed  through 
the  outer  wall.  This  is,  as  can  be  easily  understood,  a  most 
dangerous  accident.  (5)  If  the  force  of  propulsion  be  a 
little  greater,  then  the  bone  may  be  split  longitudinally, 
without  being  fractured  across,  as  in  a  case  related  by  Le- 
veille,  and  quoted  by  Malgaigne,  in  which  an  Austrian  soldier 
at  Marengo  was  struck  by  a  ball  in  the  lower  third  of  the 
leg.  He  walked  several  miles  to  the  rear,  where  he  was  seen, 
and  the  wound  thought  to  be  very  slight.  A  superficial 
exfoliation  of  the  bone  was  alone  expected  ;  however,  his 
symptoms  became  so  serious  that  the  leg  had  to  be  removed, 
when  it  was  found  that,  from  the  place  where  "the  impres- 
sion of  the  ball  v  existed,  there  proceeded  several  longitudi- 
nal and  oblique  clefts,  which  extended  from  the  lower  third 
of  the  tibia  up  to  near  the  head  of  the  bone.  (6)  Into  the 
spongy  heads  of  bones,  and,  more  rarely,  into  their  shafts,  a 
ball  may  be  driven  as  into  a  plank  of  wood,  without  almost 
any  splintering,  and  become  encysted  there.  (7)  It  may 
pass  through,  causing  a  clean  hole,  of  several  of  which 


GUNSHOT    WOUNDS    AND    THEIR   TREATMENT.  10T 

occurrences  I  will  afterward  relate  cases ;  but  the  conical 
ball  never  acts  in  any  of  these  ways,  so  far  as  I  have  seen. 
It  is  seldom  split  itself,  but  invariably  splinters  the  bone 
against  which  it  strikes  to  a  greater  or  less  degree,  accord- 
ing1 to  circumstances,  and  that  in  the  direction  of  the  bone's 
axis.  This  tendency  to  splitting  in  the  bone  shows  itself 
much  more  in  a  downward  than  in  an  upward  direction,  so 
that  the  destruction  which  such  a  ball  will  occasion  will  be 
greater  when  it  strikes  the  upper  than  the  lower  end  of  a 
shaft. 

All  kinds  of  balls  generally  fracture  and  split  the  shaft  of 
a  bone  if  they  strike  it  about  its  middle,  but  while  a  fracture 
with  but  little  comminution  results  from  the  round  ball,  the 
conical  ball — especially  that  which  has  a  broad,  deep  cup  in 
its  base — splits  and  rends  the  bone  so  extensively  that  nar- 
row fragments,  many  inches  in  length,  are  detached,  and 
lesser  portions  are  thrown  in  all  directions,  crosswise  at  the 
seat  of  fracture,  and  driven  into  the  neighboring  soft  parts. 
It  is  the  pressure  of  these  fragments,  as  will  be  shown  further 
on,  which  renders  the  fracture  of  long  bones  by  the  new  ball 
so  hopeless.*  I  had  many  most  interesting  opportunities 


*  As  instances  of  how  great  a  difference  it  makes  in  the  prognosis 
of  cases  whether  a  round  or  a  conical  ball  has  been  the  wounding 
agent,  I  may  relate  two  cases,  from  a  host  of  others.  In  the  first 
instance,  the  ball  entered  on  the  external  side  of  the  ankle,  near  the 
tendo-achillis,  and,  passing  forward  and  inward,  lodged,  as  if  in  a 
piece  of  wood,  in  the  lower  end  of  the  tibia,  close  over  the  ankle- 
joint.  When  the  ball  was  removed,  the  bone  was  found  not  to  have 
been  split  in  any  direction.  A  conical  ball  would  have,  to  a  certainty, 
opened  the  joint,  and,  in  all  probability,  so  split  the  tibia  as  to  have 
necessitated  amputation  in  the  upper  part  of  the  leg.  In  another 
case,  a  round  ball  made  a  clean  hole  through  one  of  the  condyles  of 
the  femur,  and  did  not  split  the  bone;  while,  if  a  conical  ball  had 
struck  the  same  part,  it  would  have  so  cleft  the  bone  that  amputa- 
tion in  the  middle  of  the  femur  would  have  been  called  for;  whereas 
the  removal  of  the  limb  at  the  knee-joint — a  much  less  serious  oper- 
ation— sufficed  in  the  case  referred  to. 


108  SURGERY   OF   THE   CRIMEAN   WAR. 

of  seeing  the  extraordinary  manner  in  which  the  conical  ball 
destroys  bone  in  the  way  I  refer  to.  I  have  never  met  with 
an  instance  in  which  such  a  ball,  fired  at  whatever  range, 
and  striking  at  all  perpendicularly  on  a  long  bone,  has  failed 
to  traverse  it  and  comminute  it  extensively. 

From  the  comparatively  little  employment  of  the  round 
ball  during  the  late  war,  there  were  fewer  illustrations  of 
the  splitting  of  balls  on  the  edge  of  bone,  as,  for  instance, 
on  the  edge  of  the  tibia,  or  on  the  bridge  of  the  nose,  or  on 
the  humerus,  than  usually  occur  in  a  campaign.  I  do  not 
believe  that  the  conical  ball,  with  its  immense  force  of  pro- 
pulsion, could  be  so  split.  There  is  a  case  borrowed  from 
Mr.  Wall  of  the  38th,  given  later  under  wounds  of  the  head, 
in  which  "a  round  rifle  (?)  ball"  was  thus  split  on  the  parie- 
tal bone,  one-half  entering  and  the  other  half  going  off  ex- 
ternally, in  a  soldier  of  the  38th,  wounded  on  the  8th  Sep- 
tember. Another  somewhat  similar  case  occurred  in  the 
19th  Regiment.  It  is  by  no  means  uncommon  that  a  ball 
should  be  thus  split  on  the  head.  Many  examples  of  it 
occur  in  works  on  military  surgery.  No  case  clearly  made 
out  as  one  of  splitting  came  under  my  own  notice;  but  in 
one  instance,  a  ball  so  changed  in  shape  as  to  appear  the 
section  of  one,  was  extracted  from  within  the  iliac  fossa. 
Instances  are  on  record  in  which  balls  have  been  split  into 
three  parts  by  the  bones  of  the  face  and  the  trochanter 
major. 

Although  it  cannot  be  for  a  moment  doubted  that  balls 
may  remain  for  a  lifetime  imbedded  in  bone,  and  cause  little 
if  any  annoyance,  yet  it  is  equally  certain  that  the  most 
grievous  results  much  more  frequently  arise  from  their  pres- 
ence in  such  situations.  Of  this,  innumerable  examples 
readily  occur  to  any  one  who  has  seen  many  "veterans,"  or 
who  has  read  much  on  the  subject  to  which  I  refer.  When 
speaking  of  wounds  of  the  shoulder-joint,  I  will  detail  some 
cases  which  illustrate  the  pernicious  action  of  balls  left  im- 
pacted in  bone.  Guthrie  is  very  emphatic  in  his  directions 


GUNSHOT   WOUNDS   AND   THETR   TREATMENT.  109 

to  remove  balls  so  placed,  and  predicts  the  most  disastrous 
consequences  from  the  neglect  of  this  measure.  Malgaigne, 
after  relating  several  cases  in  which  balls  have  remained 
without  causing  harm,  concludes  thus:  "It  is  necessary  to 
mention  these  fortunate  cases  as  evidence  of  the  resources 
of  nature,  but  they  hardly  serve  to  weaken  the  force  of  the 
prognosis  when  a  ball  cannot  be  extracted,  or  the  essential 
indication  of  this  sort  of  lesion — the  extraction  of  the  foreign 
body.  This  indication  is,  then,  that  of  the  first  importance." 

The  nerves  most  commonly  escape  injury  from  a  ball. 
If  the  missile  has  been  rendered  irregular  in  shape  by  pre- 
vious contact  with  some  hard  substance,  then  it  may  do 
much  damage  to  even  the  larger  nerve  trunks.  Numbness, 
succeeded  by  pain  in  the  extremity  of  a  limb  traversed  by  a 
ball,  is  riot  uncommon,  and  probably  arises  from  the  contu- 
sion or  laceration  of  some  chief  nerve — the  swelling  and  the 
pressure  it  occasions  assisting  to  give  rise  to  the  subsequent 
uneasiness.  The  paralysis  which  succeeds  the  injury  of  a 
nerve  may  come  on  at  once,  or  after  an  interval,  and  may 
or  may  not  be  accompanied  with  pain  in  the  part  itself,  or 
in  other  regions  connected  with  it  by  nervous  communica- 
tion. I  have  seen  the  hand  several  times  waste  when  some 
of  its  nerves  had  been  injured  by  a  ball.  In  one  case  in 
particular,  in  which  the  ball  had  coursed  up  under  the 
muscles  on  the  external  surface  of  the  upper  arm,  this  symp- 
tom was  very  marked. 

Even  though  making  all  due  allowance  for  the  elasticity, 
strong  coat,  mobility,  and  form  of  the  arteries,  it  is  yet 
difficult  to  understand  how  they  escape  injury  in  gunshot 
wounds  as  they  do.  The  rarity  of  primary  hemorrhage  on 
the  field  of  battle  has  been  long  remarked,  and  yet  how  often 
do  we  meet  with  ball  wounds  apparently  through  the  course 
of  a  great  vessel ! 

The  veins  are  more  easily  cut  than  the  arteries,  and  pri- 
mary hemorrhage,  when  it  does  occur,  proceeds  more  com- 
monly from  them.  Some  vessels  are  more  liable  to  injury 

10 


110  SURGERY   OP   THE    CRIMEAN    WAR. 

from  balls  than  others.  Thus,  those  firmly  tied  down,  or 
lying  on  bone,  are  more  subject  to  damage  than  those  loosely 
reposing  on  the  soft  tissues.  This  remark  applies  especially 
to  two  vessels  :  the  femoral,  as  it  passes  over  the  brim  of  the 
pelvis;  and  the  popliteal,  where  it  lies  on  the  head  of  the 
tibia.  The  lower  parts  of  the  ulnar,  the  radial,  and  the 
facial,  where  it  turns  over  the  jaw,  are  subject  to  injury  from 
the  same  reason.  An  artery  has  not  rarely  been  opened  by 
a  spiculum  of  bone  detached  by  a  ball  which  had  itself  spared 
the  artery. 

The  eccentric  course  often  pursued  by  balls  has  been  a 
frequent  subject  of  remark,  and  though  we  had  many  most 
striking  instances  of  this,  still  I  suspect  we  have  had  less  of 
it  than  occurred  in  the  experience  of  former  wars.  The 
conical  ball  seldom  fails  to  take  the  shortest  cut  through  a 
cavity  or  limb,  and  it  has  at  times  been  seen  (as  at  the  Alma) 
to  pass  through  the  bodies  of  two  men  and  lodge  in  that  of 
the  third.  But  of  the  wanderings  of  the  old  round  ball  there 
were  many  illustrations.  I  have  known  it  enter  above  the 
elbow,  and  be  removed  from  the  opposite  axilla;  and  in 
another  case  it  entered  the  right  hip,  and  was  found  in  the 
left  popliteal  space.*  This  "  bizarrerie"  in  a  ball's  course 
is  accounted  for  by  the  deflecting  action  of  tendons,  apo- 
neuroses,  or  processes  of  bone,  or  by  the  angle  at  which  the 
ball  strikes,  and  the  way  in  which,  during  certain  positions 
of  the  body,  distant  parts  are  placed  in  a  line,  as  in  the  well- 

*  The  surgeon  of  the  24th,  when  serving  in  India,  mentions  a  case 
in  one  of  his  reports,  in  which  a  ball  entered  below  the  angle  of  the 
lower  jaw,  on  the  left  side,  and  made  its  exit  above  the  spine  of  the 
right  scapula,  without  injuring  any  important  part ;  and  M.  Meniere, 
in  his  account  of  the  Hotel-Dieu  during  the  "three  days,"  tells  us 
of  a  ball  which  entered  at  the  inner  angle  of  the  left  eye,  passed 
downward,  backward,  and  to  the  right  side,  under  the  base  of  the 
cranium,  and  was  removed  above  the  right  shoulder.  The  rapid 
recovery,  without  a  bad  symptom,  was  no  less  wonderful  in  this 
case  than  the  direction  taken  by  the  missile  was  curious. 


GUNSHOT    WOUNDS    AND    THEIR   TREATMENT.  Ill 

known  case  recorded  by  Hennen,  in  which  a  ball,  entering 
the  upper  arm  of  a  man  ascending  a  scaling-ladder,  was 
found  half-way  down  the  thigh  of  the  opposite  side.  The 
fact  of  this  wandering,  however,  is  a  peculiarity  in  gunshot 
wounds  which  often  renders  the  discovery  of  the  wounding 
agent  difficult. 

Foreign  bodies,  as  pieces  of  cloth  or  part  of  the  soldier's 
accoutrements,  are  often  far  more  troublesome  when  intro- 
duced into  a  wound  than  the  ball  which  occasioned  their 
presence  there.  Innumerable  and  most  heterogeneous  have 
been  the  foreign  bodies  thus  forced  into  wounds;  but  those 
which  are  capable  of  acting  chemically  as  well  as  mechani- 
cally are  the  worst  of  all.  Of  these,  lime,  pieces  of  copper, 
etc.  are  the  most  frequently  met  with.  Round  lead  balls 
are,  perhaps,  from  their  nature  and  shape,  the  least  noxious 
of  any,  and  are  most  likely  to  become  encysted  in  the 
tissues. 

Few  questions  connected  with  gunshot  wounds  have  given 
rise  to  so  much  discussion  and  diversity  of  opinion  as  that 
with  reference  to  the  extraction  of  balls.  For  my  own 
part  I  have  seen  enough  to  make  me  subscribe,  with  all  sin- 
cerity, to  Begin's  precept,  when  he  says  in  his  communica- 
tion to  the  Academy:  "  Selon  moi  1'indication  de  leur  ex- 
traction est  toujours  presente,  toujours  le  chirurgeon  doit 
chercher  a  la  remplir ;  rnais  il  doit  le  faire  avec  la  prudence 
et  la  measure  que  la  raison  conseilie.  S'il  recussit,  il  aura 
beaucoup  fait  en  faveur  du  blesse.  S'il  s'arrete  devant  1'ini- 
possibilite  absolue  ou  devant  la  crainte  de  produire  les 
lesions  additionelles  trop  graves  il  aura  encore  satisfait  aux 
principes  de  Part;  et  quels  que  soient  les  resultats  de  la 
blessure  il  n'aura  pas  a  se  reprocher  de  les  avoir  laisse 
devenir  funestes  par  son  inertie." 

If  we  examine  into  the  opinions  of  surgeons  on  this  point, 
we  find  that  nearly  all  tho^e  who  look  upon  the  extraction 
of  the  ball  as  a  matter  of  secondary  importance  are  civilians, 
while  military  surgeons  place  great  weight  upon  its  accom- 


112  SURGERY    OF    THE    CRIMEAN    WAR. 

plishment.  The  true  way  of  putting  the  question  is,  not 
whether  balls  may  remain  in  the  body  without  causing  an- 
noyance, but  whether  they  do  so  in  so  large  a  number  of 
cases  as  to  warrant  non-interference.  We  must  always 
remember  that  "science  is  not  made  up  of  exceptions,"  but 
is  established  by  a  collection  of  positive  facts.  Those  who 
have  studied  gunshot  wounds  in  the  field,  know  full  well 
how  enormous  is  the  irritability  caused  by  the  presence  in 
a  wound  of  a  ball  or  other  foreign  body — how  restless  and 
irritable  the  patient  is  till  it  is  removed — how  prolonged 
the  period  of  treatment  is  in  the  cases  in  which  it  is  left; 
and  how  frequently  the  results  are  so  distressing  as  to  de- 
mand future  interference,  or  condemn  the  unfortunate  suf- 
ferer to  a  life  of  discomfort.  As  it  is  the  surgeon's  duty  to 
treat  his  patients  with  reference  to  their  future  ease  as  well 
as  to  their  present  cure,  so  he  should  not  try  to  bring  about 
a  healing  of  the  wound  which  can  be  only  temporary  and 
fallacious,  to  the  sacrifice  of  the  efficiency  of  a  limb  and  the 
future  health  of  the  body. 

In  this  country  we  have  not  many  opportunities  of  obtain- 
ing extensive  information  on  the  point  as  connected  with 
the  subsequent  history  of  men  with  balls  remaining  unex- 
tracted,  but  such  information  is  supplied  from  the  Hotel  des 
Invalides  of  France,  by  M.  Hutin,  the  chief  surgeon  to  that 
magnificent  establishment.  He  tells  us,  that  while  4000 
cases  had  been  examined  by  him  in  five  years,  only  twelve 
men  presented  themselves  who  suffered  no  inconvenience 
from  unextracted  balls,  and  the  wounds  of  200  continued  to 
open  and  close  continually  till  the  foreign  body  had  been 
removed.  This  epitome  is  of  much  value  in  estimating  the 
question  I  am  considering.  In  leaving  the  ball  unextracted, 
we  never  know  what  evils  may  follow.  The  keeping  open 
of  the  wound  exposes  the  patients  in  the  first  place  to  all 
the  dangers  of  a  life  in  hospital,  and  the  very  elimination  of 
the  foreign  body  by  suppuration,  if  it  take  place  at  all,  neces- 
sitates a  vast  amount  of  annoyance.  If  it  be  a  piece  of  shell 


GUNSHOT   WOUNDS   AND   THEIR   TREATMENT.  113 

or  such  like  which  is  present,  then  its  size  will  prevent  its 
unaided  extrusion,  and  the  blocking  up  of  the  track,  which 
it  is  so  apt  to  occasion,  may  cause  burrowing  abscesses  of  a 
most  destructive  character. 

Before  a  ball  becomes  encysted,  it  may  set  up  grave  in- 
flammation, which  will  mat  together  and  embarrass  parts; 
press  upon  bone,  and  perhaps  cause  exfoliation ;  ulcerate 
blood-vessels,  and  so  irritate  nerves  as  to  occasion  affections 
as  severe  and  fatal  in  their  results  as  tetanus.  It  is  some- 
what remarkable,  that  in  the  wounded  who  came  under  my 
own  care,  two  died  of  tetanus,  in  the  very  small  number  of 
instances — four  or  five  at  most — in  which  I  could  not  find 
the  ball.  If  this  was  a  mere  coincidence,  it  is  the  more 
curious.  Gravitation  and  muscular  action  may  so  change 
the  position  of  a  ball,  that  from  a  harmless  site  it  may  be 
removed  to  one  of  much  danger.  It  may  thus  work  its  way 
into  a  cavity,  and  cause  fatal  results. 

But  suppose  the  ball  to  become  encysted  in  the  first  in- 
stance, what  security  have  we  that  some  very  trivial  circum- 
stance (it  may  be  a  blow  or  even  a  deterioration  in  the  health 
of  the  patient)  may  not  set  up  irritation,  inflammation,  and 
suppuration  in  the  cyst,  and  so  come  to  set  the  ball  free 
again  to  work  harm  in  the  economy?  In  any  case  its  con- 
tinued pressure  gives  rise  to  much  uneasiness.  The  con- 
stant weight  and  weakness  felt  in  the  limb,  the  wandering 
pains,  ascribed  to  rheumatism,  from  their  aggravation  by 
cold  and  damp,  which  attack  even  distant  parts  of  the  ex- 
tremity, and  the  ever-present  dread  felt  by  the  patient,  if 
the  ball  be  in  close  neighborhood  to  any  vital  organ,  all 
unite  to  give  much  annoyance  and  discomfort. 

The  aversion  which  patients  who  have  long  carried  unex- 
tracted  balls  express  to  have  them  removed,  is  not,  as  some 
would  try  to  show,  any  proof  of  the  slight  annoyance  they 
occasion,  but  simply  indicates  that  they  choose  to  suffer  the 
discomfort  rather  than  undergo  what  appears  to  them  an 

10* 


114  SURGERY   OF    THE   CRIMEAN    WAR. 

uncertain  and  dangerous  proceeding  to  free  themselves  of  a 
bearable  inconvenience. 

It  seems,  then,  the  teaching  of  experience,  as  it  is  of 
common  sense,  that  whether  the  question  be  viewed  as  one 
bearing  immediately  or  remotely  on  the  result — on  the  cure 
of  the  patient,  in  the  proper  acceptation  of  the  term — then 
we  should,  as  soon  as  practicable,  ascertain  the  position  of 
the  ball,  remove  it  along  with  any  other  foreign  body  which 
may  have  been  introduced  with  it,  always  supposing  that  by 
such  a  proceeding  we  do  not  cause  more  serious  mischief 
than  experience  shows  the  presence  and  after-effects  of  the 
ball  can  produce. 

To  extract  a  ball  is  in  general  not  difficult.  It  is  of  much 
consequence  to  proceed  to  its  accomplishment  before  inflam- 
mation and  swelling  have  come  on,  so  as  to  close  the  wound.* 
The  great  point  to  attend  to  undoubtedly  is  the  fulfillment 
of  the  rule,  which  is  as  old  as  Hippocrates,  to  place  the 
patient  as  nearly  as  possible  in  the  same  position  as  that  he 
occupied  at  the  moment  of  injury — to  put  the  same  muscles 
into  action,  and  the  angle  which  the  parts  form  to  one 
another  in  the  same  relation;  also,  to  place  ourselves  rela- 
tively to  him  in  a  position  to  correspond  as  nearly  as  pos- 
sible with  the  direction  from  which  the  ball  came.  By 
considering  the  effect  which  bones  or  strong  tendinous  ex- 
pansions may  have  had  in  deflecting  the  ball,  or  by  paying 
attention  to  what  Guthrie  calls  the  general  "anatomy  of  the 
whole  circle  of  injury,"  and  consulting  the  patient's  own 
ideas,  which  often  convey  to  us  most  useful  hints,  we  shall 
in  general  succeed  without  much  difficulty  in  discovering 
the  ball.  An  examination  of  the  patient's  clothes  will  show 
us  whether  any  part  of  them  has  been  carried  into  and  left 
in  the  wound — whether  the  two  holes  seen  in  the  limb  have 

*  Percy  adds  another  reason  to  encourage  us  in  the  early  removal 
of  balls,  when  he  says  that  men  submit  the  more  readily  soon  after 
the  receipt  of  the  wound  to  the  necessary  incisions,  before  their 
courage  has  been  broken  by  pain  and  suppuration. 


GUNSHOT    WOUNDS    AND    THEIR    TREATMENT.  115 

been  caused  by  the  same  ball  which  has  thus  passed  out,  or 
by  two  balls  which  are  still  in;  as  well  as  whether  the  ball 
may  not  have  carried  in  a  cul-de-sac  of  the  clothes,  and 
been  withdrawn  with  it.  If  this  be  not  attended  to,  very 
awkward  mistakes  maybe  made;  as  the  mere  correspond- 
ence in  the  direction  of  the  two  apertures,  any  more  than 
their  seeming  want  of  relationship,  cannot  be  taken  as  de- 
cisive in  settling  the  matter.  This  point  is  well  illustrated 
iu  the  following  instance  related  by  an  Indian  surgeon  :  A 
wound  was  found  below,  and  another  above,  the  patella  of  a 
wounded  man.  The  former  had  all  the  signs  of  the  wound 
of  entrance,  and  the  latter  those  usually  found  at  the  place 
of  exit  of  a  ball.  The  opening  of  an  abscess,  which  formed 
in  the  thigh  a  fortnight  after,  gave  exit  to  a  grape-shot,  and 
it  was  found  that  the  external  condyle  had  been  injured,  and 
that  each  opening  had  been  caused  by  a  different  ball. 

In  another  instance,  which  occurred  in  the  case  of  a 
soldier  of  the  40th  Regiment  in  Cabul,*  the  ball  appeared 
to  have  passed  through  the  elbow-joint,  and  to  have  frac- 
tured the  radius.  There  were  two  openings,  having  all  the 
appearance  of  being  those  of  entrance  and  exit;  yet  the 
ball  was  found  and  removed  from  the  limb  three  weeks  after. 
Such  a  mistake  is  most  apt  to  arise  when  two  balls  have 
been  fired  together  from  the  same  gun,  which  happens  not 
uncommonly  in  civil  commotions,  or  when  such  fire-arms  are 
used  as  the  "espignol"  of  the  Danes,  from  which  a  number 
of  balls  are  fired  in  rapid  succession,  or  when  a  cartridge, 
similar  to  that  used  during  the  Sleswick-Holstein  war,  is 
employed,  in  which  two  balls  and  a  piece  of  lead  are  bound 
up  together.  One  ball,  too,  it  should  be  remembered,  may 
make  several  openings.  Thus,  I  have  seen  two  in  the  leg 
and  two  in  the  hip,  and  also  two  iu  either  thigh,  occasioned 
in  each  case  by  one  ball.  Dupuytren  relates  a  case  in  which, 
from  its  splitting,  one  ball  made  five  holes ;  and  the  younger 

*  Unpublished  Report. 


116  SURGERY    OP   THE   CRIMEAN    WAR. 

Larrey  saw  at  Antwerp  six  orifices  caused  in  the  same  way. 
Sir  Stephen  Hammick  mentions  a  case  in  which  an  aperture 
was  found  on  either  side  of  the  chest  of  an  officer  shot  in  a 
duel.  These  corresponded  both  in  position  and  character  to 
those  which  would  be  occasioned  by  a  ball  that  had  tra- 
versed the  chest ;  yet  after  death  two  balls  were  found  in 
the  body. 

As  showing  the  necessity  of  an  early  and  careful  search, 
as  well  as  that  we  should  never  rely  too  much  on  the 
patient's  statement,  I  may  mention  the  following  case  :  A 
soldier,  wounded  on  the  18th  June,  came  under  my  care  in 
the  general  hospital.  His  right  arm,  which  had  been  frac- 
tured compoundly,  was  greatly  swollen  at  the  time  of  admis- 
sion. I  was  told,  and  accepted  the  story,  that  the  accident 
had  been  caused  by  a  piece  of  shell,  to  which  species  of  injury 
the  wound  bore  every  resemblance,  and  that  it  had  been 
removed  by  a  surgeon  in  one  of  the  trenches.  At  the 
earnest  solicitation  of  the  patient,  I  contented  myself  with 
applying  the  apparatus  necessary  to  save  the  limb  without 
minutely  examining  the  wound.  The  injury  turned  out  to 
be  much  masked,  and  to  be  greatly  more  severe  than  it  at 
first  appeared,  the  shaft  of  the  humerus  having  been  split 
into  the  joint.  When  removing  the  limb  at  the  shoulder, 
some  days  after,  to  my  great  astonishment  a  large  grape- 
shot  dropped  from  among  the  muscles.*  I  before  alluded 
to  another  case  in  which  a  piece  of  shell,  weighing  nearly 
three  pounds,  had  remained  concealed  for  two  months  with- 
out suspicion,  from  a  like  neglect  of  a  proper  examination. 

It  is  well  to  remember  also,  in  searching  for  balls,  that 
they  may  have  dropped  out  by  the  same  aperture  by  which 
they  entered,  before  we  come  to  examine  the  case.  Stro- 
meyer  has  put  us  upon  our  guard  against  very  curious 

*  I  may,  however,  remark  that  this  splitting  upward  of  the  head 
from  the  shaft  is  very  rare.  la  general,  the  splitting  ceases  at  the 
epipbysis. 


GUNSHOT   WOUNDS   AND   THEIR   TREATMENT.  lit 

errors,  which  he  says  he  has  seen  made  in  cutting  on  the 
head  of  the  fibula,  and  on  a  metatarsal  bone  for  balls. 

Sir  Charles  Bell  has  shown  how  the  nerves  may  indicate 
to  us  the  position  of  the  ball.  In  one  case  he  found  it  by 
pressing  on  the  radial  nerve,  and  so  discovering  that  the 
ball  lay  behind  it.  "  So  when  a  ball  has  taken  its  course 
through  the  pelvis  or  across  the  shoulder,  the  defect  of 
feeling  in  the  extremity,  being  studied  anatomically,  will 
inform  you  of  its  course — that  it  has  cut  or  is  pressing  on  a 
certain  trunk  of  nerve." 

From  all  this,  then,  it  is  at  the  least  very  evident  that  we 
should  not  be  too  hasty  in  concluding  that  no  ball  remains 
in  the  limb,  even  although  all  the  signs  usually  indicative  of 
its  having  escaped  are  present;  and  also,  that  immediately 
before  proceeding  to  take  any  steps  for  the  removal  of  a 
ball,  we  should  make  certain  of  its  position,  remembering 
the  rule  laid  down  by  Dupuytren — never  to  act  upon  infor- 
mation regarding  the  site  of  a  ball  obtained  the  day  before, 
from  the  rapid  manner  in  which  they  often  shift  from  one 
spot  to  another. 

The  common  dressing  forceps,  if  long  enough  and  fine 
enough  in  the  handle,  will,  I  believe,  be  found  the  most 
useful  bullet  extractor.  That  invented  by  Mr.  Tuffnel,  of 
Dublin,  acted  well  in  the  few  cases  in  which  I  tried  it. 
Larrey  employed  polypus  forceps  in  preference  to  anything 
else;  but  the  inventions  which  have  been  made  to  accom- 
plish this  simple  end  are  innumerable.  To  support  the 
limb  with  the  disengaged  hand  on  the  side  opposite  to  that 
at  which  we  introduce  the  forceps,  is  of  much  importance. 
If  the  course  of  the  ball  has  been  from  above  downward,  and 
if  it  has  approached  at  all  near  the  surface,  it  should  always 
be  cut  upon  at  the  dependent  part,  by  which  two  objects  are 
secured — the  removal  is  facilitated,  and  an  opening  for  the 
pus  is  insured.  If  the  wound  be  large,  as  it  generally  is 
from  the  conical  ball,  the  finger  forms  the  best  probe,  both 
to  discover  the  ball  and  also  to  examine  the  state  of  the 


118          SURGERY  OF  THE  CRIMEAN  WAR. 

adjoining  parts;  otherwise  a  large  gum-elastic  bougie  is 
our  best  resource.  Causing  the  patient  to  move  his  limb, 
sometimes  makes  the  site  of  the  ball  be  felt  by  him,  if  not  by 
us.  Its  position  under  a  fascia,  or  in  contact  with  a  bone, 
would  make  us  risk  much  in  order  to  remove  it. 

The  contentment  of  mind  which  results  from  the  extrac- 
tion assists  recovery  amazingly.  The  long  continuance  of 
the  discharge,  its  gleety  character,  and  the  persistence  of 
pain  in  the  track  almost  always  proceed  from  the  presence 
of  some  foreign  body — it  may  be  a  mere  shred — in  the 
wound.  Chloroform  is  of  inestimable  service  to  us,  both  in 
the  examination  of  wounds  and  in  the  removal  of  balls. 
All  those  voluntary  muscular  contractions  which,  although 
they  are  apt  to  interpose  obstacles  to  our  examination,  were 
not  presented  to  the  entering  ball,  are  done  away  with,  and 
the  severe  pain  which  a  prolonged  examination  and  difficult 
extraction  give  rise  to  is  avoided.  We  must,  however,  be 
careful  to  obtain  from  the  patient  all  the  information  he  can 
give  us,  before  we  bring  him  under  the  influence  of  the 
anesthetic. 

The  inflammation  which  ensues  in  a  gunshot  wound, 
shortly  after  its  infliction,  makes  itself  visible  in  the  swelling 
and  consequent  eversion  of  the  lips  of  both  entrance  and 
exit  wounds,  in  the  general  tumefaction  of  the  parts,  and  in 
the  augmented  pain.  It  was  the  fear  of  this  inflammation 
strangulating  the  parts  which  gave  rise  to  the  exploded 
custom  of  scarifying  the  wound.*  The  swelling  will  differ 

*  Hunter  expresses,  with  his  usual  clearness,  the  principles  which 
should  guide  us  in  enlarging  a  wound,  or  "scarifying,"  as  it  was 
called.  "No  wound,"  he  says,  "let  it  be  ever  so  small,  should  be 
made  larger,  except  when  preparatory  to  something  else,  which  will 
imply  a  complicated  wound,  and  which  is  to  be  treated  accordingly. 
It  should  not  be  opened  because  it  is  a  wound,  but  because  there  is 
something  necessary  to  be  done  which  cannot  be  executed  unless  the 
wound  is  enlarged.  This  is  common  surgery,  and  ought  also  to  be 
military  surgery  respecting  gunshot  wounds." — Hunter's  Collected 
Works,  vol.  iii.  p.  549. 


GUNSHOT    WOUNDS    AXD    THEIR   TREATMENT.  119 

much  in  different  regions  and  in  different  constitutions.  In 
parts  strongly  bound  down,  in  irritable  tissues,  in  lax  disten- 
sible parts  it  will  vary  ranch,  while,  according  as  the  patient 
is  of  an  inflammatory,  lymphatic,  or  nervous  temperament, 
the  effect  will  differ  not  a  little. 

The  constitutional  fever  which  sets  in  is  generally  pro- 
portioned to  the  importance  of  the  part  implicated,  though 
most  anomalous  exceptions  do  occur.  This  fever  will  often 
put  on  the  characters  of  the  endemic  or  epidemic  fever;  but 
in  war  the  tendency  seems  generally  to  be  to  a  low  typhoid 
type,  unless  there  be  a  decided  local  influence  in  action,  as 
that  arising  from  paludal  emanations.  With  us,  the  symp- 
tomatic fever  must  have  been  comparatively  slight  and  eva- 
nescent to  what  it  was  in  the  Peninsula.  The  severe  remedies 
put  in  force  by  the  surgeons  of  Wellington's  army  never 
could  have  been  employed  by  us.  That  old  soldiers,  if 
sober,  are  much  less  affected  by  this  constitutional  disturb- 
ance than  others,  is  I  think  very  observable. 

The  mitigation  of  the  constitutional  fever  and  of  the  local 
inflammation,  the  prevention  of  all  accumulations  of  matter, 
by  making  judicious  escapes  for  it,  the  relaxation  of  severed 
muscular  fiber,  the  application  of  light,  unirritating  dressings, 
rest,  and  attention  to  the  essential  principles  of  all  surgery, 
comprise  the  general  treatment  which  gunshot  wounds  usually 
demand.  In  the  early  stages  cold  may  be  of  use  locally — 
even  ice,  as  recommended  by  Baudens — and  in  wounds  of 
the  hand  and  forearm  irrigation  is  of  the  greatest  service  ; 
but  when  inflammation  and  suppuration  are  present,  hot  ap- 
plications will  always  be  found  of  most  good.  Strict  atten- 
tion to  the  position  of  the  limb  is  of  great  consequence,  and 
though  in  general  it  may  be  desirable,  as  in  some  instances 
it  is  absolutely  necessary,  to  restrict  the  diet,  yet  in  those 
cases  in  which  much  suppuration  is  to  be  expected,  very 
great  latitude  should  be  observed  with  reference  to  such  a 
rule.  Soldiers  in  war  are  commonly  easily  depressed,  and 
should  not  be  fed  too  sparingly  when  admitted  into  hospital, 


120  SURGERY    OF    THE   CRIMEAN    WAR. 

unless  they  suffer  from  a  wound  of  the  head,  chest,  or  abdo- 
men. Without  placing  too  much  faith  on  the  happy  effects 
which  Malgaigne  tells  us  the  Russian  wounded,  treated  in 
Paris  in  1814,  derived  from  a  stimulant  diet,  as  contrasted 
with  the  Prussians,  French,  and  Austrians,  still  it  is  un- 
questionable that  there  is  too  much  tendency  to  look  on  the 
common  run  of  gunshot  wounds  as  highly  inflammatory,  and 
to  treat  them  accordingly.  Velpeau's  rule  on  this  point 
agrees  with  his  usual  intelligent  views,  when  he  says  he  lays 
it  down  as  a  rule  to  remove  his  wounded  and  operated  on  as 
little  as  possible  from  their  ordinary  diet  when  they  are 
hungry,  and  when  there  is  no  disturbance  of  the  digestive 
and  circulatory  systems. 

We  found  cod-liver  oil  of  the  greatest  use  in  those  cases 
in  which  the  waste  by  discharge  was  great.  A  stream  of 
lukewarm  water,  made  to  pass  by  gentle  syringing  from  one 
opening  to  the  other,  forms  one  of  the  most  useful  methods 
of  treating  gunshot  wounds  Any  shreds  of  cloth,  clots  of 
blood,  pus,  etc.,  which  may  be  in  the  wound  and  sustain  the 
suppuration,  will  thus  be  got  rid  of  with  very  little  disturb- 
ance to  the  parts.  The  addition  of  a  little  of  Burnett's 
solution  to  the  water  thus  used,  or  to  the  water-dressing, 
was  useful  at  the  same  stage.  Of  the  tonic  and  stimulant 
injections  recommended  by  writers  I  had  no  experience  ;  but 
I  have  seen  the  French  employ,  with  apparent  advantage,  a 
lotion  composed  of  one  part  perchloride  of  iron  and  three  of 
water  in  profusely  suppurating  wounds. 

The  extreme  simplicity  of  the  appliances  and  dressings 
employed  during  this  war,  and  the  nearly  total  absence  of 
poultices,  and  such-like  "cover-sluts,"  would,  I  think,  have 
pleased  Mr.  Gnthrie.  The  "  stuffing  in  of  great  tents"  was, 
I  need  not  say,  unknown  ;  and  though  we  ascribed  wondrous 
virtues  to  cold  water,  it  was  not  on  account  of  any  "magical 
or  unchristian "  power  which  we  supposed  it  to  possess. 
Water-dressings,  and  the  lightest  possible  bandaging  con- 
sistent with  the  fulfillment  of  well-understood  ends,  were 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT.     121 

prevalent  in  our  army,  but  not  to  the  same  extent  among 
our  allies,  who  have  not  yet  given  up  the  weighty  pledgets 
of  charpe  and  much  fine  linen,  which  so  greatly  astonish  the 
English  surgeon.  The  splints  and  other  apparatus  used  par- 
took of  the  simplicity  of  the  rest  of  the  treatment.  Stiff 
bandages  were  too  little  used,  if  we  accept  the  experience 
of  the  Sleswick-Holstein  war;  but  the  difficulty  of  always 
getting  the  necessary  materials  in  the  field  is  somewhat 
opposed  to  their  use. 

The  state  of  the  weather  has  got  much  to  do  with  the 
rapid  cure  of  gunshot,  as  of  all  other  wounds.  From  a 
perusal  of  the  medical  records  of  regiments  serving  in  the 
Colonies,  it  would,  however,  appear  that  hot  weather,  as  in 
India,  is,  on  the  whole,  more  favorable  than  a  cold  climate. 

Shell  wounds,  and  grazes  by  round  shot,  are  often  fol- 
lowed by  much  injury,  little  suspected,  but  deeply  seated, 
resulting,  not  unfrequently,  in  wide-spread  sloughing  of  the 
soft  parts.  I  cannot  avoid  relating  the  following  case,  al- 
though it  did  not  occur  in  the  Crimea,  as  it  is  a  most  excel- 
lent illustration  not  only  of  the  great  and,  it  may  be,  little 
suspected  harm  which  may  be  occasioned  by  a  round  shot, 
but  also  because  it  is  an  instance  of  what  would  have  been 
in  former  times  set  down  to  the  wind  of  the  ball.  It  is  from 
the  records  of  the  medical  department.  Private  John  Con- 
ally  was  hit  at  Sadoolapore  by  a  round  shot  on  the  outer 
side  of  the  right  arm  and  thorax.  A  blue  mark  alone  was 
occasioned  on  the  arm,  and  little  or  no  mark  was  found  on 
the  chest.  He  died  in  twenty  hours,  without  having  rallied 
from  the  shock.  The  peritoneal  cavity  was  found  full  of 
dark  blood.  The  right  lobe  of  the  liver  was  torn  into  small 
pieces,  "some  of  which  were  loose,  and  mixed  with  blood. 
There  was  no  sign  of  inflammation  in  the  peritoneum,  and 
the  other  viscera  were  healthy."  Shell  does  not  comminute 
bone  so  much  as  a  rifle-ball,  but  it  tears  the  soft  parts  much 
more  considerably.  To  refute  the  old  myth  concerning  the 
effects  of  the  wind  of  a  passing  ball,  calls  not  even  for  pass- 

11 


122  SURGERY    OF    THE    CRIMEAN  ' WAR. 

ing  mention  in  a  work  of  modern  times.  All  the  cases  of 
this  description  of  which  I  heard,  were  quite  explicable  on 
the  suppositions  laid  down  by  Vacher,  in  his  memoir  upon 
this  subject.  Under  wounds  of  the  head,  I  have  mentioned 
a  case  (Quin)  which  would  undoubtedly  be  set  down  of  old 
as  having  been  so  caused.  There  were  many  instances  of 
the  very  near  approach  and  even  slight  contact  of  round 
shot,  without  any  inconvenience  arising,  further  than  might 
be  looked  for  from  the  unexpected  and  unwelcome  vicinity  of 
such  an  intruder. 


CHAPTER   VI. 

The  Use  of  Chloroform  in  the  Crimea — Primary  and  Secondary  Hemor- 
rhage from  Gunshot  Wounds — Tetanus — Gangrene — Erysipelas — Frost- 
bite. 

THE  advantages  derived  from  the  use  of  anesthetics  are 
perhaps  more  evident  and  more  appreciated  in  the  field  than 
in  civil  practice.  The  many  dreadful  injuries  which  are  pre- 
sented to  us  in  war,  and  the  severe  suffering  which  so  often 
results  from  them,  soon  cause  us  fully  to  appreciate  the  ben- 
efits bestowed  by  such  "  pain-soothers." 

The  vast  majority  of  the  surgeons  of  the  Eastern  army 
were  most  enthusiastic  in  their  anticipations  of  what  chloro- 
form was  to  accomplish.  It  was  expected  to  revolutionize 
the  whole  art  of  surgery.  Many  operations,  hitherto  dis- 
carded, were  now  to  be  performed  ;  and  many,  which  the 
experience  of  the  Peninsula  said  were  necessary,  were  hence- 
forth to  be  done  away  with. 

In  the  British  army  chloroform  was  almost  universally 
employed  ;  but  although  the  French  also  used  it  very  exten- 
sively, as  we  learn  from  Baudens,  still  I  do  not  think,  from 
what  I  saw  of  its  employment  in  their  hospitals,  that  they 
had  our  confidence  in  it.  Baudens  tells  us  *  that  "  they  had 
no  fatal  accident  to  deplore  from  its  use,  although  during 
the  Eastern  campaign  chloroform  was  employed  thirty  thou- 
sand times,  or  more.  In  the  Crimea  alone,"  he  continues, 
"  it  was  administered  to  more  than  twenty  thousand  wound- 
ed, according  to  the  calculations  of  M.  Scrive." 

In  one  division  of  our  army  it  was  not  so  commonly  used 

*  Revue  dcs  Deux  Mondes,  Apr.  1857. 

(123) 


124  SURGERY    OF    THE    CRIMEAN   WAR. 

as  in  the  others,  from  an  aversion  to  it  entertained  by  the 
principal  medical  officer  of  the  division — a  gentleman  of 
very  extensive  experience.  The  only  case  in  which,  with 
any  show  of  fairness,  fatal  consequences  could  be  said  to 
have  followed  its  use,  occurred  in  the  division  referred  to. 
The  patient,  a  man  of  thirty-two  years  of  age,  belonged  to 
the  62d  Regiment,  and  was  about  to  have  a  finger  removed. 
The  chloroform  was  administered  on  a  handkerchief,  as  he 
sat  in  a  chair.  Death  was  sudden;  and  artificial  respira- 
tion, which  was  the  means  of  resuscitation  employed,  failed 
to  restore  him.  No  pathological  condition  sufficient  to  ac- 
count for  death  was  found  post-mortem.  Some  five  or  six 
other  cases  were  brought  forward,  by  the  small  body  of  sur- 
geons who  were  suspicious  of  the  action  of  chloroform,  as 
having  ended  fatally  from  its  effects ;  but  in  none  of  these 
could,  I  think,  the  least  pretext  be  found  for  the  imputation, 
further  than  that  the  anesthetic  had  been  administered  at 
some  period  previous  to  death.  A  man  who  had  been  dread- 
fully mutilated,  and  who  had  lost  much  blood,  died  shortly 
after  having  his  thigh  removed  high  up.  Chloroform  had 
been  used,  and  to  it  was  ascribed  the  fatal  issue.  Death, 
twenty  or  thirty  hours  after  a  capital  operation,  rendered 
necessary  by  the  most  dreadful  injuries,  must  be  attributed 
to  the  chloroform,  and  so  on,  and  no  note  taken  of  the  effects 
of  severe  injury,  plus  a  capital  operation,  in  shattering  the 
already  enfeebled  powers  !  Death  occurring  under  such  cir- 
cumstances, when  no  chloroform  was  employed,  would  not 
be  thought  to  demand  any  special  explanation,  nor  does  the 
fact  that  the  injury  was  occasioned  by  a  round  shot  intro- 
duce any  new  element  into  the  calculation. 

The  objections  made  to  the  use  of  chloroform  were  re- 
stricted to  two  classes  of  cases — trivial  accidents,  in  which 
it  was  thought  unnecessary  to  run  the  risk  of  giving  it,  and 
amputations  of  the  thigh,  in  which  a  fatal  accession  of  shock 
was  feared.  However  this  may  be,  it  certainly  shows  the 
little  practical  force  of  these  objections  that,  while  with 


THE    USE   OF   CHLOROFORM.  125 

every  indulgence  in  the  interpretation  of  the  law  post  hoc, 
etc.,  only  some  half-dozen  cases  could  be  obtained  through- 
out the  whole  army  to  illustrate  the  pernicious  effects  of  this 
agent,  and  that,  too,  when  thousands  upon  thousands  had 
been  submitted  to  its  action,  and  hundreds  of  surgeons  of 
equal  experience  to  the  objectors  were  ready  to  record  their 
unqualified  opinion  in  its  favor,  as  well  as  their  gratitude  for 
its  benefits.  For  my  own  part,  I  never  had  reason,  for  one 
moment,  to  doubt  the  unfailing  good  and  universal  applica- 
bility of  chloroform  in  gunshot  injuries,  if  properly  admin- 
istered. I  most  conscientiously  believe  that  its  use  in  our 
army  directly  saved  very  many  lives — that  many  operations 
necessary  for  this  end  were  performed  by  its  assistance  which 
c.ould  not  otherwise  have  been  attempted — that  these  oper- 
ations were  more  successfully,  because  more  carefully,  exe- 
cuted— that  life  was  often  saved  even  by  the  avoidance  of 
pain — the  morale  of  the  wounded  better  sustained,  and  the 
courage  and  comfort  of  the  surgeon  increased.  I  think  I 
have  seen  enough  of  its  effects  to  conclude  that,  if  its  action 
is  not  carried  beyond  the  stage  necessary  for  operation,  it 
does  not  increase  the  depression  which  results  from  injury, 
but  that,  on  the  contrary,  it  in  many  instances  supports  the 
strength  under  operation.  Its  usefulness  is  seen  in  nothing 
more  than  when,  by  its  employment,  we  perform  operations 
close  upon  the  receipt  of  injury,  and  thereby,  if  not  entirely, 
at  least  in  a  great  degree,  are  able  to  ward  off  that  embran- 
lement  of  the  nervous  system  which  is  otherwise  sure  to  fol- 
low, and  whose  nature  we  know  only  by  its  dire  effects. 

To  men  who  had  lost  much  blood  it  had,  of  course,  to  be 
administered  with  great  care,  from  the  rapidity  of  its  ab- 
sorption in  such  persons  ;  but  if  we  do  not  act  on  broader 
principles  in  its  exhibition  than  reckoning  the  number  of 
drops  which  have  been  employed,  or  the  part  of  the  nervous 
system  which  we  may  presume  to  be  at  the  time  engaged, 
then  we  must  expect  disastrous  results.  It  is  difficult  to 
see  how  its  use  could  favor  secondary  hemorrhage  after  op- 

11* 


126  SURGERY   OF   THE   CRIMEAN    WAR. 

eration,  as  some  said  it  did  ;  but  it  is,  on  the  contrary,  easy 
to  understand  how  the  opposite  result  might  follow.  That 
purulent  absorption  should  prevail  among  men  so  broken  in 
health  as  our  men  were,  need  not  be  explained  by  the  em- 
ployment of  chloroform  ;  and  that  ice  would  prove  more 
useful,  in  the  slighter  operative  cases  in  field  practice,  few 
will  be  disposed  to  admit,  either  on  the  ground  of  time,  effi- 
ciency, or  opportunity.  To  Deputy  Inspector- General  Taylor 
we  owe  the  practical  observation,  that  chloroform  appears 
to  act  more  efficiently  when  administered  in  the  open  air. 

In  the  prolonged  searches  which  are  sometimes  necessary 
for  the  extraction  of  foreign  bodies,  chloroform  is  useful, 
not  only  in  preventing  pain,  but  also  in  restraining  muscular 
contractions,  by  which  obstacles  are  thrown  in  the  way  of 
our  extraction  which  did  not  oppose  themselves  to  the  intro- 
duction of  the  body.  Then  much  is  gained  in  field  practice 
by  the  mere  avoidance  of  the  patient's  screams  when  under- 
going operation,  as  it  frequently  happens  that  but  a  thin 
partition,  a  blanket  or  a  few  planks,  intervene  between  him 
who  is  being  operated  upon  and  those  who  wait  to  undergo 
a  like  trial.  Thus  when,  as  after  a  general  engagement,  a 
vast  number  of  men  come  in  quick  succession  to  be  subjected 
to  operation,  it  is  a  point  of  great  importance  to  save  them 
from  the  depression  and  dread  which  the  screams  and  groans 
of  their  comrades  necessarily  produce  in  them. 

It  is  therefore  my  clear  conviction  that  the  experience  of 
the  late  war,  as  regards  chloroform,  is  unequivocally  favor- 
able ;  that  it  has  shown  that  chloroform,  both  directly  and 
indirectly,  saves  life  ;  that  it  abates  a  vast  amount  of  suffer- 
ing; that  its  use  is  as  plainly  indicated  in  gunshot  as  in  other 
wounds  ;  and  that,  if  administered  with  equal  care,  it  matters 
not  whether  the  operation  about  to  be  performed  be  necessi- 
tated by  a  gunshot  wound,  or  by  any  of  the  accidents  which 
occur  in  civil  life. 

Hemorrhage  was  in  the  olden  time  the  great  bugbear  of 
the  military  surgeon,  and  that  against  which  his  field  arrange- 


HEMORRHAGE   FROM   GUNSHOT   WOUNDS.  127 

ments  were  chiefly  directed.  It  is  not  now,  however,  so 
much  feared,  from  its  being  well  known  not  to  be  of  so  fre- 
quent occurrence  on  the  field,  and  the  means  of  arresting  it 
being  better  understood.  Blandin,  in  his  communication  to 
the  Academy,  says  that  his  observation  of  gunshot  wounds 
led  him  to  believe  that  primary  bleeding  always  takes  place 
if  a  vessel  of  any  size  is  injured,  but  that  it  is  soon  spon- 
taneously arrested  by  an  action  similar  to  that  which  takes 
place  when  a  limb  is  torn  off.  Sanson  repeats  the  remark 
as  to  the  constant  presence  of  hemorrhage  to  some  extent 
at  the  moment  of  injury.  Guthrie  did  good  service  to 
surgery  by  showing  how  small  a  force  can  obstruct  a  vessel 
of  the  first  order.  He  thereby  gave  courage  and  confidence 
to  both  surgeon  and  patient. 

It  has  been  the  experience  of  most  wars,  certainly  of  the 
late  one,  that  tourniquets  are  of  little  use  on  the  battle-field  ; 
for  though  it  is  unquestionable  that  a  large  number  of  the 
dead  sink  from  hemorrhage,  still  it  would  be  impossible, 
amid  the  turmoil  and  danger  of  the  fight,  to  rescue  them 
in  time,  the  nature  of  the  wounds  in  most  of  these  cases 
causing  death  very  rapidly.*  A  great  artery  is  shot  through, 
and  in  a  moment  the  heart  has  emptied  itself  by  the  wound. 
It  would  be  an  experiment  of  some  danger,  but  of  much  in- 
terest, as  bearing  on  this  question,  to  examine  the  bodies  of 
the  slain  immediately  after  a  battle,  and  carefully  record  the 
apparent  cause  of  death  in  each  case.f 


*  Although  this  is  true  as  a  general  rule,  yet  both  Larrey  and 
Colles  relate  instances  in  which,  by  prompt  assistance,  death  was 
prevented  in  wounds  opening  the  carotid  artery. 

f  The  only  mention  I  have  been  able  to  meet  with,  in  the  records 
of  the  medical  department,  of  the  causes  of  death  on  (lie  field,  is  in 
a  report  from  the  surgeon  of  the  41st,  when  serving  in  Cabul.  lie 
mentions  that  of  four  men  who  were  killed  outright,  three  wove 
wounded  through  the  chest,  and  one  through  the  head.  After  the 
contests  in  Paris  in  1830,  Menierc  tells  us  that  it  v.as  a  common 
observation  at  the  Morgue,  to  which  the  dead  were  carried,  that  the 
greatest  number  h:id  been  shot  through  (he  chest. 


128  SURGERY    OF    THE    CRIMEAN    WAR. 

I  before  remarked  how  curiously  arteries  escape  injury 
from  a  ball  passing  through  a  limb.  In  the  course  of  the 
femoral  vessels  this  is  very  commonly  seen.  Through  the 
axilla,  through  the  neck,  out  and  in  behind  the  angles  of  the 
jaw,  between  the  bones  of  the  forearm,  and  even  of  the  leg, 
balls  of  various  sizes  and  shapes  pass  without  injury  to  the 
vessels.  Thus,  the  neck  has  suffered  severe  injury  many 
times,  and  yet  very  few  deaths  appear  in  the  returns  from 
these  wounds.  I  have  never  myself  seen  any  case  in  which 
a  bullet  has  passed  harmlessly  between  a  large  artery  and  its 
vein,  but  many  such  cases  are  on  record. 

The  following  may  be  mentioned  as  instances  of  narrow 
escapes  :  A  soldier  was  wounded  at  Inkerman,  by  a  ball 
which  entered  through  the  right  cheek,  and  escaped  behind 
the  angle  of  the  opposite  jaw,  tearing  the  parts  in  such  a 
manner  that  the  great  vessels  were  plainly  seen,  bare  and 
pulsating,  in  the  wound.  Three  weeks  after  admission  into 
hospital  he  was  discharged,  never  having  had  a  bad  symp- 
tom. A  soldier  of  the  Buffs  was  wounded  in  June,  1855, 
by  a  rifle-ball,  which  struck  him  in  the  nape  of  the  neck. 
It  passed  forward  round  the  right  side  of  neck,  going  deeply 
through  the  tissues ;  turning  up  under  the  angle  of  the  in- 
ferior maxilla,  it  fractured  the  superior  maxillary  and  malar 
bones,  destroyed  the  eye,  and  escaped,  killing  a  man  who 
was  sitting  beside  him.  This  patient  made  a  rapid  recovery. 
A  French  soldier  at  the  Alma  was  struck  obliquely  by  a 
rifle-ball,  near  to  but  outside  the  right  nipple  ;  the  ball 
passed  seemingly  quite  through  the  vessels  and  nerves  in 
the  axilla,  and  escaped  behind.  His  cure  was  rapid  and 
uninterrupted.  Another  Frenchman  was  struck  in  the 
trenches  by  a  ball,  a  little  below  the  middle  of  the  right 
clavicle.  The  ball  escaped  behind,  breaking  off  the  upper 
third  of  the  posterior  border  of  the  scapula,  and  yet  he  re- 
covered perfectly,  without  any  bleeding  taking  place.  End- 
less numbers  of  similar  cases  are  presented  to  us  in  military 
hospitals. 


HEMORRHAGE    FROM   GUNSHOT    WOUNDS.  129 

A  considerable  artery  may  be  fairly  cut  across,  and  give 
no  further  trouble,  beyond  the  first  gush  of  blood  which 
takes  place  at  the  moment  of  injury.  In  such  cases,  the 
vessel  contracts  and  closes  itself.  If  only  half  divided,  as  it 
is  apt  to  be  by  shell,  or  by  the  quick  passage  of  a  ball,  then 
the  hemorrhage  will  be,  in  all  probability,  fatal.  The  best 
example,  perhaps,  on  record  of  the  former  result,  is  that 
mentioned  by  Larrey.  A  soldier,  struck  on  the  lower  third 
of  the  thigh  by  a  ball,  suffered  one  severe  hemorrhage,  which 
was  never  repeated.  The  limb  became  cold,  the  popliteal 
ceased  to  beat,  and  the  ends  of  the  divided  femoral  could  be 
felt  retracted  when  the  finger  was  placed  in  the  wound. 
This  man  recovered  perfectly.  The  younger  Larrey  records 
a  very  curious  case  from  the  wounded  at  the  siege  of  Ant- 
werp. A.  shell  passed  between  a  man's  thighs,  and,  destroy- 
ing the  soft  parts,  divided  both  feraorals ;  yet  there  was  no 
hemorrhage,  although  the  pulsation  continued  in  the  upper 
ends  of  the  vessels  to  within  a  few  lines  of  their  extremities. 

The  speed  of  the  ball  at  the  moment  when  it  comes  in 
contact  with  an  artery  has  a  good  deal  to  do  with  the  injury 
it  inflicts.  If  it  be  in  full  flight  it  may  so  cut  open  the  vessel 
as  to  allow  of  instantaneous  hemorrhage  ;  whereas,  if  its 
speed  be  much  diminished,  the  contusion  it  occasions  opposes 
immediate,  but  favors  secondary  bleeding. 

Primary  hemorrhage  may  take  place  either  instantaneously 
on  the  receipt  of  a  wound,  or  after  a  little  time,  when  the 
faintness  resulting  from  the  accident  has  gone  off.  I  have 
already  referred  to  some  instances  in  which  the  former  is 
liable  to  otcur.  In  wounds  of  the  face,  too,  this  instant- 
aneous bleeding  is  very  usual. 

Some  cases  occurred  in  the  Crimea  of  the  well-known 
fact  that  limbs  may  be  carried  away,  and  their  arteries 
loosely  from  the  shattered  stump,  without  bleeding.  Two 
came  under  my  own  notice,  in  which  legs  were  carried  away 
by  round  shot,  and  no  hemorrhage  took  place,  though  both 
men  died  subsequently  from  other  causes.  This  spontaneous 


130          SURGERY  OP  THE  CRIMEAN  WAR. 

cessation  of  hemorrhage  is  perhaps  most  commonly  seen  in 
the  upper  arm. 

The  returns  fail  to  inform  us  of  the  number  of  cases, 
either  absolutely  or  proportionately  to  the  whole  number  of 
wounds,  in  which  secondary  hemorrhage  took  place  during 
the  war.  Although  I  have  no  figures  to  which  I  can  refer 
as  corroborating  the  statement,  yet  I  am  inclined  to  think 
that  the  proportion  of  cases  in  which  serious  bleeding  did 
take  place  is  higher  than  that  set  down  by  Mr.  Guthrie. 
The  distinction  drawn  by  Dr.  John  Thomson  between 
secondary  hemorrhage,  proceeding  from  sloughing,  uleera- 
tion,  and  excited  arterial  action  as  it  occurs  at  different 
stages  of  treatment,  is  a  good  one.  That  which  takes  place 
after  twenty-four  hours  and  up  to  the  tenth  day  being 
usually  due  to  sloughing,  resulting  directly  from  the  injury, 
should  always  have  the  term  "intermediary"  applied  to  it; 
and  the  bleeding  which  proceeds  from  morbid  action,  such 
as  ulceration  attacking  the  part,  and  which  takes  place  at  a 
later  period,  would  be  more  appropriately  called  "par  excel- 
lence "  secondary.  Hemorrhage  should  thus  be  distinguished 
into  three  periods:  primary,  occurring  within  twenty-four 
hours;  intermediary,  between  that  and  the  tenth  day;  and 
secondary,  that  which  takes  place  at  a  later  date.  More 
precision  would  be  given  to  our  language  on  this  important 
subject,  by  such  a  distinction  being  always  recognized. 

The  period  at  which  consecutive  bleeding  is  most  apt  to 
take  place  has  been  variously  estimated.  Guthrie  sets  it 
down  as  occurring  from  the  eighth  to  the  twentieth  day, 
Dupuytren  from  the  tenth  to  the  twentieth,  Hennen  from  the 
fifth  to  the  eleventh,  and  Roux  from  the  sixth  to  the  twen- 
tieth. In  the  cases  I  have  myself  observed,  it  has  taken 
place  between  the  fifth  and  twenty-fifth  days,  and  by  a  curi- 
ous coincidence,  it  has  appeared  in  the  majority  on  the  fif- 
teenth after  the  receipt  of  the  wound.  In  one  case,  a  wound 
without  fracture  of  the  thigh,  it  was  said  to  have  taken  place 


HEMORRHAGE    FROM   GUNSHOT    WOUNDS.  131 

as  late  as  the  seventh  week,  and  th#t  when  no  gangrene  or 
apparent  ulceration  was  present. 

Consecutive  hemorrhage  may  occur  from  very  insignificant 
vessels,  and  be  arrested  by  simple  means ;  but  when  it  takes 
place  from  a  large  arterial  trunk,  it  is  an  accident  of  the 
most  serious  importance.*  With  us,  in  particular,  such 
effusions  were  causes  of  extreme  anxiety,  as  the  deteriorated 
state  of  the  health  of  our  patients  made  such  an  accident 
peculiarly  disastrous.  Their  strength  could  not  withstand 
such  a  drain,  and  the  scurvy  made  their  blood  so  thin  and 
effusible  that  they  were  liable  to  great  loss  of  blood,  not  by 
vigorous  hemorrhages,  but  by  slow,  though  not  less  destruc- 
tive discharges.  From  this  it  can  be  understood  that  in  the 
Crimea  many  of  the  time-honored  remedies  for  hemorrhage, 
such  as  venesection,  starving,  etc.,  were  entirely  discarded, 
and  replaced  most  generally  by  their  opposites.  Tonics,  as 
quinine  and  iron,  were  the  remedies  most  wanted ;  and  as  to 
styptics  given  internally,  they  always  appeared  to  me  to 
be  mere  farces,  except  in  so  far  as  they  acted  as  general 
tonics. 

The  more  useful  prophylactics  to  such  consecutive  hemor- 
rhages, such  as  quiet  of  mind  and  perfect  rest  of  the 
wounded  part,  are  not  always  attainable  in  field  practice, 
especially  when  the  necessity  of  removing  patients  occurs  so 

*  The  following  is  a  very  interesting  case  of  secondary  hemorrhage 
caused  by  the  limited  ulceration  of  a  large  artery,  which  is  related 
by  Dr.  Scott  of  the  32d,  in  a  report  existing  in  the  archives  of  the 
medical  department:  "Private  John  Hodgson,  aged  thirty-one, 
was  struck  by  a  ball  at  Mooltan,  about  a  line  anterior  to  the  left 
carotid  artery,  below  where  it  divides  into  the  external  and  internal, 
and,  passing  through  the  oesophagus,  escaped  at  a  point  correspond- 
ing to  its  entrance.  No  unfavorable  symptom  appeared  for  nine 
days,  when  a  fit  of  coughing  came  on,  and  blood  issued  from  both 
the  mouth  and  the  wounds,  and  the  patient  instantly  expired.  The 
rvjld  carotid  had  been  grazed  at  its  bifurcation,  and  a  piece  of  it, 
about  the  size  of  a  small  pea,  and  including  all  its  coats,  had  sphace- 
lated, and,  giving  way,  caused  death  before  assistance  could  be  got." 


132  SURGERY    OF   THE    CRIMEAN    WAR. 

frequently.  It  is  of  course  impossible  altogether  to  avoid 
such  movements  during  war,  but  it  is  most  unfortunate  that 
they  fall  so  often  to  be  executed  at  the  very  period  when 
they  become  most  dangerous.  No  man,  at  all  severely 
wounded  by  gunshot,  can  be  considered  safe  from  hemor- 
rhage till  his  wound  is  closed,  but  yet,  after  twenty-five  days, 
the  danger  may  be  said  to  be  in  a  great  measure  overcome. 
In  reference  to  this  point  a  siege  has  an  advantage  over  an 
open  campaign,  from  the  greater  fixedness  of  the  hospitals, 
and  the  less  frequent  moving. 

Hemorrhage  occurring  early  was  universally  treated  by 
the  rule  laid  down  by  Bell  and  Guthrie,  of  tying  both  ends 
of  the  bleeding  vessel.  When,  however,  the  bleeding  ap- 
pears at  a  late  date,  when  the  limb  is  much  swollen,  its 
tissues  infiltrated,  matted  together,  and  disorganized,  it  is 
by  no  means  an  easy  thing  to  follow  this  practice.  The  dif- 
ficulty is  perhaps  greatest  in  wounds  of  the  calf  of  the  leg, 
where  the  muscles  are  much  developed,  when  the  posterior 
tibial  has  repeatedly  bled,  the  wound  large  and  irregular,  the 
contusion  severe,  and  the  blood  welling  out  from  among  the 
disorganized  tissues  in  no  collected  stream.  The  rules  and 
precepts  laid  down  in  books  about  the  appearance  of  the 
vessel  and  the  orifice,  about  the  mode  of  passing  a  probe 
toward  it  from  the  surface,  and  the  best  way  of  cutting  so 
as  to  fall  upon  the  vessel,  are  all  worse  than  useless,  as  they 
lead  us  to  expect  guides  where  there  are  none  but  those 
which  watchful  eyes  and  careful  incisions  afford. 

From  the  results  of  several  cases  which  fell  under  my 
observation  in  the  East,  I  have  reason  to  believe  in  the 
soundness  of  the  views  lately  put  forth  by  Nelaton,  in  oppo- 
sition to  the  long-credited  opinion  of  Dupuytren,  as  to  the 
unsound  state  of  the  artery  in  suppurating  wounds.  I  feel 
pretty  sure  that  the  vessel  will,  in  most  cases,  bear  a  liga- 
ture for  a  sufficient  time  to  fulfill  the  end  we  have  in  view  in 
its  application.  It  will  be  necessary  to  attach  it  with  cau- 
tion, to  employ  no  more  force  than  is  absolutely  necessary, 


HEMORRHAGE   FROM   GUNSHOT   WOUNDS.  133 

and  we  may  expect  it  to  separate,  as  Ne'laton  shows,  before 
the  usual  time,  yet  it  will  continue  attached  sufficiently  long 
to  close  the  vesse:,  if  we  do  not  keep  pulling  at  it  so  as  to 
tear  it  away  prematurely.  It  requires  but  a  small  force  to 
oppose  the  blood-impulse,  and  that  the  vessel  will  commonly 
stand,  if  carefully  handled. 

The  French,  although  generally  applying  the  ligature  at 
the  seat  of  injury  in  primary  hemorrhage,  perform  Anel's 
operation  when  the  bleeding  appears  late.  The  teaching  of 
Dupuytren  ancl  Roux  has  done  much  to  prevent  "the  Eng- 
lish practice"  being  so  fully  followed  as  it  is  with  us.  * 

*  M.  Roux,  in  the  second  volume  of  his  recently  published  post- 
humous works,  thus  sums  up  his  experience  on  secondary  hemor- 
rhage from  gunshot  wounds.  It  proceeds,  he  says,  from  (1)  separa- 
tion of  the  eschar;  (2)  from  injury  by  fractured  bones;  (3)  from 
the  capillaries  caused  by  general  feebleness  in  the  patient ;  (4)  hem- 
orrhage from  the  erosion  or  tearing  of  a  vessel  appears  later  than 
that  arising  from  the  separation  of  the  eschar,  the  one  appearing 
about  the  eighth  or  tenth  day,  and  the  other  from  the  fifteenth  to  the 
twentieth  ;  (•">)  hemorrhage  arising  from  the  tearing  of  a  vessel,  and 
especially  that  which  accompanies  compound  fracture,  is  more  com- 
mon in  wounds  of  the  thigh  than  any  other;  (G)  whatever  be  its 
cause,  the  manifestation  of  the  bleeding  is  very  uncertain,  being 
sometimes  preceded  by  symptoms  which  announce  its  approach,  and 
sometimes  giving  no  indications  of  its  coming — sometimes  it  appears 
in  large  quantities,  and  very  suddenly,  while  at  other  times  it  appears 
in  small  quantities,  and  will  often  recur  if  no  interference  be  had  re- 
course to;  (7)  sometimes  the  bleeding  takes  place  within  the  limb, 
where  it  forms  a  sort  of  false  aneurism,  but  at  other  times  it  flows 
freely  outward ;  (8)  when  the  bleeding  vessel  can  be  got  at,  we 
should  ligature  it,  or  the  trunk  from  which  it  proceeds;  (il)  here,  as 
in  the  case  of  all  traumatic  hemorrhages,  primary  or  secondary,  it 
is  best  to  lie  the  vessel  in  the  wound,  above  and  below  the  place  of 
injury  ;  in  general,  however,  it  will  be  necessary  to  ligature  the  ves- 
sel at  a  distance  on  the  distal  side  of  the  wound,  after  the  methods 
of  Anel  or  Hunter,  because  the  difficulties  of  finding  it  are  great, 
and  its  state  in  the  wound  will  not  allow  of  a  ligature  being  applied 
to  it  there. 

Sanson,  again,  (Des  Iltemorrhagies  Trauma! ique?,)  concludes  thus: 
12 


134  SURGERY   OF    THE   CRIMEAN    WAR. 

Ariel's  operation  is  undoubtedly  the  best  in  one  class  of 
cases  dwelt  upon  by  Dupuytren,  in  which  hemorrhage  arises 
from  the  tearing  of  an  artery  in  a  simple  fracture.  The 
ligature  of  the  main  vessel  commonly  succeeds  in  these  cases, 
while  to  find  the  bleeding  vessel  is  most  difficult,  and  to 
expose  the  seat  of  fracture  to  the  air  is  a  risk  greater  than 
should  be  encountered. 

There  are,  unquestionably,  some  situations  where  it  is  im- 
possible to  get  at  the  wounded  vessel,  especially  when  the 
bleeding  has  taken  place  at  a  late  date.  The  deep  branches 
of  the  carotid  afford,  perhaps,  the  most  patent  example.  In 
a  case  of  this  sort,  in  which  the  deep  temporal  and  internal 
maxillary  were  wounded,  in  a  Russian  admitted  into  the 
general  hospital  after  the  assault  in  September,  Mr. 
Maunder  tied  the  carotid  to  arrest  the  bleeding,  which  had 
recurred  several  times,  notwithstanding  pressure.  The  liga- 
ture of  the  main  vessel  commanded  the  hemorrhage,  although 
the  patient  subsequently  died  of  exhaustion. 

Secondary  hemorrhage  may  appear  at  a  very  late  date 
from  ulceration,  set  up  by  the  pressure  of  a  fragment  of 

"A  ligature  applied  to  the  two  ends  of  a  divided  artery  is  the  surest 
method  of  arresting  the  bleeding,  and  to  prevent  a  return.  But  we 
do  not  think,  after  the  example  of  the  English  surgeons,  that  it 
should  be  put  in  force  in  all  cases,  and  whatever  be  the  situation  of 
the  artery,  from  the  risk  of  causing  great  destruction,  violent 
inflammations,  and  long  suppurations.  We  often  meet  with  wounds 
attended  with  hemorrhage,  or  false  primitive  aneurisms,  in  which  it 
is  difficult  or  impossible  to  determine  which  is  the  divided  vessel.  In 
other  cases  we  recognize  the  source  of  the  bleeding,  but  it  is  situated 
too  deeply  for  us,  without  causing  grave  injury,  to  find  and  tie  the 
artery  above  and  below  the  wound.  We  are  thus  compelled  to  liga- 
ture this  artery,  or  at  least  the  trunk  from  which  it  proceeds,  between 
the  heart  and  the  wound,  but  at  a  considerable  distance  from  the 
latter.  It  is  true  that  traumatic  hemorrhages  are  much  less  favor- 
able than  aneurisms,  properly  so  called,  to  the  success  of  Anel's 
method.  But  it  is  a  necessity  in  a  way,  and  besides,  we  can,  if  the 
method  of  Anel  fails,  have  recourse  at  a  later  period  to  the  ligature 
of  the  two  ends  in  those  cases  in  which  it  is  possible." 


HEMORRHAGE    FROM    GUNSHOT   WOUNDS.  135 

bone  pressing  upon  the  vessel.  The  ulcerative  process  in 
these  cases  is  sometimes  very  slow. 

The  following  case  is  interesting,  and  conveys  much  in- 
struction as  to  the  value  of  the  different  places  in  which  to 
apply  the  ligature :  A  Russian  boy  who  had  sustained  a 
compound  fracture  of  the  leg  at  Inkerman,  from  gunshot, 
was  received  into  the  French  hospital  at  Pera  a  few  days 
afterward.  On  the  fifteenth  day  from  the  date  of  injury, 
profuse  hemorrhage  took  place  from  both  openings.  Pres- 
sure failed  to  arrest  it.  The  popliteal  was  tied  the  same 
day,  according  to  the  method  recommended  by  M.  Robert, 
viz.,  on  the  inner  side  of  the  limb,  between  the  vastus  and 
hamstring  muscles.  The  foot  remained  very  cold  for  four 
days,  and  then  violent  reaction  set  in  ;  and  on  the  eighth 
day  from  the  ligature  of  the  main  vessel  hemorrhage  recurred, 
both  from  the  original  wound  and  the  incision  of  ligature. 
Pressure  was  again  tried  in  vain.  The  superficial  femoral 
was  next  ligatured,  on  the  tenth  day  from  the  deligation  of 
the  popliteal.  Four  days  afterward  the  bleeding  returned 
from  the  wound,  and  pressure  then  seemed  to  check  it.  The 
ligature  separated  from  the  femoral  on  the  twelfth  day  after 
its  being  applied,  and  the  third  day,  i.e.  the  twenty-fifth  day 
from  the  first  occurrence  of  the  hemorrhage,  bleeding  having 
again  set  in  from  the  wound,  the  limb  was  amputated  high 
in  the  thigh,  and  the  unfortunate  patient  ultimately  recovered. 
Would  Mr.  Guthrie  not  have  saved  this  boy's  limb,  and  the 
surgeons  much  trouble  ? 

In  gunshot  wounds  of  regions  where  the  vascular  com- 
munications are  at  all  free,  the  ligature  of  the  main  trunk 
for  consecutive  bleeding  cannot  often  be  of  any  use,  as  it  is 
seldom  possible  to  be  sure  that  the  hemorrhage  proceeds 
from  the  main  vessel,  nor  yet  can  we  by  such  an  operation 
cut  off  the  collateral  circulation.  If  the  source  of  the 
hemorrhage  could  be  certainly  ascertained,  and  if  pressure 
could  be  applied  to  the  lower  portion  of  the  divided  vessel 
at  the  same  time,  then  we  might  reasonably  hope  to  arrest 


136          SURGERY  OF  THE  CRIMEAN  WAR. 

the  bleeding  by  tying  the  main  artery;  but  the  mere  placing 
of  a  ligature  on  the  proximal  side  can  give  no  security 
against  the  continuance  of  the  bleeding.  If  the  sloughing 
preceding  and  accompanying  the  bleeding  be  extensive,  and 
situated  in  a  muscular  and  vascular  part  like  the  calf  of  the 
leg,  and  if  the  hemorrhage  has  continued  notwithstanding 
the  employment  of  means  applied  locally,  I  should  never 
hesitate  between  amputation  and  ligature  of  the  main  trunk, 
but  have  instant  recourse  to  the  former,  as  being  the  only 
reliable  and  satisfactory  proceeding.*  The  following  may 
be  taken  as  a  good  example  of  a  class  of  cases  frequently 
occurring :  M'Gartland,  a  soldier  of  the  38th  Regiment,  an 
unhealthy  man,  who  was  still  suffering  from  the  effects  of 
scurvy  and  fever,  was  shot  from  the  outside  and  behind,  for- 
ward and  inward  through  the  left  leg,  on  the  18th  of  June. 
The  fibula  was  broken,  and  the  edge  of  the  tibia  was  injured. 
He  walked  to  the  rear  without  assistance.  On  admission 
into*  the  hospital,  the  limb  was  greatly  swollen.  This  swell- 
ing, by  appropriate  means,  very  much  diminished  in  a  few 
days.  On  the  fifth  day  arterial  bleeding,  to  a  limited  extent, 
took  place  from  both  openings.  Recalling  a  case  put  on 
record  by  Mr.  Butcher,  of  Dublin,  of  a  wound  of  the  post 
tibial,  I  determined  on  trying  the  effects  of  well-applied 

*  I  may  note  the  following  figures,  in  passing,  as  a  small  contribu- 
tion to  the  statistics  of  this  question:  The  French,  in  one  hospital 
at  Constantinople,  ligatured  the  femoral  at  a  distance  from  the  wound 
for  secondary  hemorrhage  seven  times,  and  all  failed.  The  subcla- 
vian  was  ligatured  under  like  circumstances  once,  and  it  succeeded. 
I  have  found  the  detailed  report  of  only  four  cases  in  which  the  main 
vessel  was  lied  in  India.  The  ligature  was  applied  twice  to  the 
femoral,  once  to  the  brachial,  and  once  to  the  radial.  It  succeeded 
in  arresting  the  hemorrhage  in  three  cases ;  one  femoral  failed.  Du- 
puytren  ligatured  the  femoral  several  times  for  bleeding  from  the 
calf,  but  with  what  result  it  is  impossible  always  to  make  out. 
S.  Cooper,  while  he  once  successfully  took  up  the  popliteal  for 
secondary  hemorrhage  from  a  wound  of  the  posterior  tibial,  strongly 
reprehends  the  practice  as  a  general  rule. 


HEMORRHAGE    FROM    GUNSHOT    WOUNDS.  137 

pressure  along  the  course  of  the  popliteal  and  in  the  wound, 
combined  with  cold  and  elevation.  The  limb  was  also  fixed 
on  a  splint.  The  object  of  the  pressure  on  the  main  vessel 
was  to  diminish,  not  arrest,  the  flow  of  blood  through  it. 
On  the  eighth  day  there  was  again  some  oozing.  Pus  had 
accumulated  among  the  muscles  of  the  calf,  and  required 
incision  for  its  evacuation.  On  the  ninth  day  a  pulsating 
tumor  was  observed  on  the  external  aspect  of  the  leg,  "the 
consecutive  false  aneurism"  of  Foubert,  and  next  day  the 
bleeding  returned  from  both  wounds.  I  wished  then  to  cut 
down  and  tie  the  vessel  in  the  wound,  but  a  consultation  de- 
cided on  waiting  a  little  longer,  in  the  hope  that  the  bleed- 
ing might  not  return.  On  the  night  of  the  eleventh  day 
most  profuse  hemorrhage  recurred.  The  attendant,  though 
strictly  enjoined  to  tighten  the  tourniquet,  failed  to  do  so, 
but  the  necessary  steps  to  arrest  the  bleeding  were  taken  by 
the  officer  on  duty.  Next  morning,  when  I  first  heard  of 
the  occurrence,  I  found  the  patient  blanched,  cold,  and  nearly 
pulseless.  A  consultation  decided  that  the  state  of  the  parts 
made  the  securing  of  the  vessel  in  the  wound  very  problem- 
atical, and  that,  as  the  limb  would  not  recover  if  the  main 
artery  was  taken  up,  amputation  must  be  performed  so  soon 
as  the  patient  had  rallied.  When  reaction  had  fairly  taken 
place,  I  amputated  the  limb.  The  removed  parts  were  much 
engorged,  sloughed,  and  disorganized.  The  anterior  tibial 
was  found  to  have  been  opened  for  about  an  inch  shortly 
after  its  origin,  and  on  it  was  formed  the  aneurism,  which 
had  a  communication  with  both  orifices  of  the  wound. 

In  all  such  cases  the  second  bleeding  should  determine 
active  interference.  I  say  the  second  bleeding,  as  it  very 
often  happens  that  when  hemorrhage  has  taken  place  once, 
even  to  a  considerable  extent,  and  evidently  from  a  vessel  of 
large  caliber,  it  never  recurs.  Many  most  striking  instances 
of  this  have  come  under  my  notice.  But  though  more  than 
even  this  is  true,  and  that  frequently  blood  thrown  out  re- 
peatedly is  spontaneously  arrested,  still  the  great  preponder- 

12* 


138  SURGERY    OF    THE   CRIMEAN    WAR. 

ance  of  cases  in  which  it  recurs  in  dangerous  repetitions  and 
quantities,  as  in  the  above  instance,  should  cause  us,  I  be- 
lieve, to  interfere  on  its  second  appearance,  more  particularly 
if  the  bleeding  be  in  any  quantity.  Not  to  interfere  unless 
the  vessel  is  bleeding,  must  not  always  be  understood  too 
literally,  or  we  will  often  be  prevented  from  performing  the 
operation  till  our  patient  is  beyond  our  help.  The  hemor- 
rhage recurs  over  and  over  again,  and  the  surgeon,  though  as 
near  as  is  practicable,  arrives  only  in  time  to  see  the  bed 
drenched,  and  the  patient  and  attendant  intensely  alarmed. 
There  is  at  the  moment  no  bleeding,  and  he  vainly  hopes 
there  will  be  no  return  ;  and  so  on  goes  the  game  between 
ebbing  life  and  menacing  death,  the  loss  not  great  at  each 
time,  but  mighty  in  its  sum,  till  all  assistance  is  useless. 
Many  a  valuable  life  has  thus  been  lost  which  might  have 
been  saved  by  a  more  decided  course  of  action. 

Few  cases  are  more  embarrassing  than  these  to  the  sur- 
geon, or  require  more  determination  and  well-considered 
resolution  to  conduct  to  a  successful  issue.  One  is  averse 
to  act  when  the  immediate  necessity  has  passed  ;  and  unless 
we  be  guided  in  our  course  by  a  knowledge  of  general  re- 
sults, more  than  by  the  immediate  case  in  hand,  we  will  lose 
many  a  patient.  These  cases  form  an  exception  to  the 
rational  surgery  of  the  day,  which  prescribes  inaction,  unless 
there  be  immediate  call  for  interference.  There  can  be 
little  doubt  that  hemorrhage  may  often  be  definitely  arrested 
by  pressure  applied  with  care  along  an  extensive  part  of  the 
wounded  artery,  as  well  as  to  the  apertures  ;  but  such  treat- 
ment is  not  adapted  for  gunshot  wounds,  from  the  depth 
and  narrowness  of  their  tracks,  unless  we  so  enlarge  them  as 
to  admit  the  compress  deep  into  the  wound.  This  was  shown 
in  the  case  recorded  above,  as  well  as  in  many  others.  The 
discharge  is  pent  up  by  the  plug,  and  burrows  largely  among 
the  tissues. 

There  were  many  cases  of  hemorrhage  from  the  hand,  suc- 
ceeding gunshot  wounds,  which  came  under  my  notice  during 


HEMORRHAGE    FROM   GUNSHOT    WOUNDS.  139 

the  war.  Many  of  the  injuries  resulted  from  the  accidental 
explosion  of  the  patient's  own  gun,  and,  I  suspect,  in  not  a 
few  cases  from  intention.  Hemorrhage,  in  such  instances, 
was  at  times  very  troublesome,  especially  when  the  bones  of 
the  hand  were  much  fractured,  as  it  was  then  difficult,  if  not 
impossible,  to  secure  the  vessel  in  the  wound.  The  secondary 
bleeding  usually  appeared  early  in  these  cases,  and,  so  far  as 
my  observation  went,  ligature  of  the  brachial  seems  better 
practice,  when  local  means  fail,  than  putting  a  thread  on  the 
vessels  of  the  forearm,  as  I  saw  done  several  times  in  the 
East.  In  recent  cases  we  can  often  ligature  the  bleeding 
vessel,  but  in  the  sloughing  stage,  with  a  deep  wound,  and 
the  bones  much  injured,  it  is  impossible  to  secure  it.  To 
ligature  the  radial  and  ulnar,  separately  or  conjointly,  ex- 
poses the  patient  to  operative  dangers  which  bring  no  ade- 
quate return,  as  the  probability  of  success  is  very  small.  In 
the  following  case,  the  ligature  of  the  vessels  of  the  forearm 
succeeded  ;  but  in  four  other  cases,  in  which  I  knew  it  tried 
for  wounds  of  the  palm,  it  failed  utterly.  The  position  of 
the  wound  in  this  case  made  it  more  likely  that  the  proceed- 
ing followed  should  succeed:  A  soldier,  resting  his  right 
hand  on  his  musket,  was  struck  by  a  ball  on  the  web  be- 
tween the  thumb  and  forefinger.  The  wound  seemed  trivial, 
but  the  whole  hand  swelled  exceedingly.  On  the  fourteenth 
day  arterial  hemorrhage  occurred,  and  pressure  was  applied. 
The  bleeding  repeatedly  recurred,  and  still  pressure  was  per- 
severed in.  Finally,  the  radial,  and  then  the  ulnar,  were 
ligatured  before  the  hemorrhage  was  commanded.  An  early 
search  in  the  wound  would  probably  have  succeeded  in 
securing  the  vessel. 

I  have  seen  the  method  of  pressure  on  the  brachial  by 
flexing  the  arm  and  by  bandaging ;  both  fail  in  some  of 
these  cases. 

Hemorrhage  from  the  face  of  stumps  is  unquestionably 
one  of  the  most  disagreeable  complications  which  can  arise 
during  their  treatment.  The  scorbutic  state  of  the  blood  of 


140  SURGERY    OF   THE   CRIMEAN    WAR. 

most  of  our  men  made  their  stumps  highly  irritable,  and 
liable  to  sanguinolent  oozing.  Their  strength  was  thus 
much  wasted,  and  other  complications  of  hardly  less  serious 
importance  were  superinduced.  All  noticed  the  prevalence 
of  these  bleedings  when  the  hot  sirocco  blew,  or  previous  to 
those  violent  thunder-storms  which  did  so  much  to  clear  the 
air.  The  patients  often  complained  at  these  times  of  feeling 
"  as  if  their  stumps  would  burst,"  and  the  bleeding  seemed 
to  give  them  much  relief.  The  blood  which  flowed  was 
commonly  more  venous  than  arterial,  thin,  watery,  and  of  a 
brick-dust  color.  When  cold  air  or  water,  combined  with 
elevation,  failed  to  check  it,  pressure  and  the  perchlorate  of 
iron  generally  succeeded.  Its  appearance  was  always  an 
indication  for  more  fresh  air,  tonics,  and  better  food.* 

Guthrie  counsels  us,  in  the  event  of  hemorrhage  from  a 
thigh  stump  which  cannot  be  commanded  by  the  application 
of  a  ligature  to  the  bleeding  point,  to  tie  the  main  vessel,  in 
the  first  instance,  at  a  point  the  nearest  to  the  end  of  the 
stump,  at  which  pressure  commands  it,  provided  it  be  be- 
yond the  sphere  of  the  inflammation  ;  and  if  this  fail,  then 
to  reamputate  the  limb.  He  adds,  that  if  pressure  above  the 
going  off  of  the  profunda  is  necessary  to  command  the  bleed- 
ing, then  we  should  amputate,  in  place  of  tying  the  vessel  in 
the  groin.  The  dictates  of  so  great  a  master  are  not  lightly 
to  be  controverted,  but,  so  far  as  my  comparatively  very 
limited  observation  goes,  I  would  be  diyposed  to  tie  the  iliac, 
rather  than  either  ligature  the  femoral  high  up,  or  reampu- 
tate the  limb;  this  is,  of  course,  always  providing  that  the 

*  Briot  (Hist,  de  la  Chir.  Milit.)  remarks  that  strong,  vigorous  sub- 
jects are  not  those  in  whom  he  has  seen  hemorrhage,  either  primary 
or  secondary,  most  commonly  follow  gunshot  wounds;  but,  on  the 
contrary,  it  was  more  common  in  patients  of  an  opposite  character. 
This  he  ascribes  to  the  want  of  tone  in  these  men,  preventing  the 
contraction  or  closure  of  the  vessels.  The  same  thing,  he  says, 
exists  in  the  power  we  have  of  arresting  bleeding  in  primary  and 
secondary  operations — those  necessitated  by  accident  and  disease. 


HEMORRHAGE   FROM   GUNSHOT    WOUNDS.  141 

vessel  could  not  be  secured  on  the  face  of  the  stump.  Bleed- 
ing from  a  thigh  stump  is  so  apt  to  proceed  from  one  of  the 
deep  vessels,  and  to  be  temporarily  arrested  by  a  tourniquet 
applied  to  the  femoral,  but  whose  strap  encircles  the  limb, 
that  no  ligature  of  the  femoral  much  above  the  extremity  of 
the  stump  could  give  any  security  against  a  return.  The 
fear  of  gangrene  in  depressed  subjects  when  the  iliac  is  tied, 
is  the  chief  objection  to  the  practice  I  allude  to. 

The  cases  in  which  attempts  were  made  in  the  East  to 
arrest  hemorrhage  from  stumps,  by  applying  a  ligature  to 
the  main  vessel  above  the  extremity  of  the  stump,  were,  I 
believe,  singularly  unfortunate.  Well-applied  pressure  along 
the  course  of  the  principal  vessel,  adapted  to  diminish  the 
circulation  through  it,  has  sufficed,  in  some  few  most  threaten- 
ing cases,  finally  to  arrest  bleedings  which  had  recurred  fre- 
quently ;  but  in  these  cases  the  implication  of  the  main  vessel 
was  clearly  made  out.  Take  the  following  case  as  an  ex- 
ample. The  state  of  the  vessel,  as  discovered  after  death, 
also  lends  an  interest  to  the  narrative.  Hemorrhage  took 
place  to  a  slight  extent,  from  a  thigh  stump,  on  the  ninth 
day  after  operation,  and  was  repeated  on  the  following 
morning.  A  tourniquet  was  applied  over  the  course  of  the 
femoral,  so  as  to  moderate  the  flow  of  blood  through  it.  On 
the  fourteenth  day  the  bleeding  returned,  and  the  tourniquet 
was  tightened  for  four  hours,  so  as  almost  to  arrest  the  cur- 
rent of  blood  in  the  great  vessel,  and  afterward,  though 
loosened,  was  still  left  so  tight  as  to  restrain  the  free  flow  of 
the  blood  through  the  main  artery.  On  the  sixteenth  day  the 
bleeding  returned,  and  the  same  treatment  was  followed,  the 
position  of  the  compressing  force  being  carefully  shifted  from 
time  to  time.  From  this  period  the  hemorrhage  never  reap- 
peared. The  patient  subsequently  died  of  pyaBmia,  when  it 
was  found  that  an  abscess  had  formed  around  the  great 
vessels,  extending  from  the  end  of  the  stump  upward  for 
some  inches ;  that  the  artery  was  fairly  opened  by  ulcera- 
tion,  to  the  extent  of  an  inch  from  its  termination,  but  be- 


142  SURGERY    OF   THE   CRIMEAN    WAR. 

yond  that  distance  a  dense  clot  occupied  its  caliber  for  an 
inch  and  a  quarter.  The  vein  contained  much  pus.  Puru- 
lent matter  was  freely  deposited  in  the  lungs.  Here  the 
ulceration  of  the  end  of  the  artery  allowed  the  bleeding  to 
take  place,  while  the  subsequent  formation  of  a  clot  above 
arrested  it. 

The  exact  number  of  cases  in  which  tetanus  has  followed 
wounds  during  the  war,  or  the  nature  of  the  injuries  giving 
rise  to  it,  I  have  failed  to  learn  from  the  army  returns.  It 
was  not,  however,  by  any  means  common.  I  know  of  six 
cases  only  which  occurred  in  camp,  and  seven  which  took 
place  at  Scutari.  The  usual  proportion  to  wounds  is, 
according  to  Alcock,  one  in  seventy-nine.  We  have  cer- 
tainly not  had  that  ratio.*  In  no  case,  the  particulars  of 
which  I  could  learn,  did  it  occur  after  the  twenty-second 
day — the  limit  as  defined  by  Sir  James  M'Gregor.  In  the 
cases  of  which  I  have  known  the  details,  there  was  no  con- 
firmation of  Baron  Larrey's  theory  as  to  the  set  of  muscles 
affected  according  to  the  position  of  the  wound.  The  cases 
occurring  in  our  army  have  been,  so  far  as  I  know,  with  one 
exception,  universally  fatal.  Of  the  six  instances  which 
appeared  in  front,  one  followed  a  compound  fracture  of  the 
thigh,  one  a  face  wound  with  destruction  of  the  eye,  one  an 
amputation  at  the  shoulder,  one  a  flesh  wound  of  the  leg, 
and  the  other  two  cases  following  wounds,  without  fracture 
of  the  thigh,  unfortunately  happened  under  my  own  charge 
in  neighboring  wards  in  the  general  hospital,  and  within  a 
very  short  time  of  one  another.  Of  those  which  appeared 
at  Scutari,  one  followed  an  amputation  of  the  hand,  two 
succeeded  compound  fractures  of  the  thigh,  one  was  a 
frost-bite  of  the  toes,  one  was  a  compound  fracture  of  the 
leg,  and  of  the  other  two  cases  I  could  not  learn  the  primary 


*  In  the  Sleswick-Holsteiii  war,  Stromeyer  had  six  cases  in  a  list 
of  2000  wounded. 


TETANUS.  143 

lesion.*  I  give  the  particulars  of  my  own  cases,  from  their 
presenting  some  points  of  interest,  of  which  not  the  least 
was  their  extreme  similarity  to  one  another. 

*  In  the  records  of  the  army  in  India  I  have  been  able  to  find  de- 
tails of  nineteen  cases  of  tetanus,  of  whom  only  one  recovered.  The 
patient  had  received  a  severe  burn  from  an  explosion  of  powder,  and 
was  treated  by  the  "injection  and  inhalation  of  sulphuric  ether." 
In  three  cases  it  followed  amputation  ;  in  three,  balls  lodged  in  bone; 
in  four,  flesh  wounds;  one,  a  penetrating  wound  of  the  chest;  one, 
a  contusion  of  the  face;  one,  a  wound  of  the  hand;  one,  a  needle 
broken  in  the  heel ;  one,  the  exposure  of  a  suppurating  wound  to  cold 
air;  one,  an  injury  of  the  foot;  in  one,  a  compound  fracture;  and  in 
one,  an  injury  of  the  ankle. 

Alcock  reports  seventeen  cases.  In  ten  the  disease  followed  flesh 
wounds,  (three  of  the  upper  extremity,  three  of  the  lower,  and  one  of 
the  trunk.)  In  two  it  followed  wounds  of  the  foot;  in  four,  com- 
pound fracture;  in  one,  a  primary  amputation.  All  died  except  two, 
one  of  whom  was  treated  by  opiates  alone,  the  other  by  opiates  suc- 
ceeded by  large  doses  of  carbonate  of  iron. 

Larrey  makes  reference  to  many  cases  in  his  memoir  in  the  cam- 
paigns in  Egypt  and  Germany.  He  says  it  was  less  acute  in  the 
latter  than  in  the  former  country.  In  Egypt  I  find  reference  made 
to  upwards  of  thirty  cases,  the  details  of  many  of  which  are  not 
given.  All  seem  to  have  died  within  a  week  of  the  appearance  of  the 
symptoms.  One  followed  a  slight  wound  of  the  face;  another,  a 
wound  of  the  hand ;  another,  a  wound  of  the  ear.  Three  were  cases 
of  flesh  wounds.  One  was  an  amputation  of  the  foot;  one,  an  ampu- 
tation of  the  arm ;  one,  a  wound  of  the  foot ;  and  one  was  caused  by 
a  fish-bone  sticking  in  the  throat.  In  the  German  campaign  no  num- 
bers are  given;  but  of  those  mentioned,  two  were  amputations  of  the 
thigh  ;  one,  a  wound  by  round  shot,  of  the  back  :  another,  a  similar 
wound  of  the  leg;  another,  a  wound  of  the  hand;  and  the  sixth  was 
a  lance  wound  of  the  forehead.  Several  of  these  recovered  after 
section  of  the  nerve. 

In  the  Hotel-Dieu,  in  July,  1830,  they  had  but  one  case  of  tetanus, 
among  the  81)0  patients  wounded  by  gunshot,  treated.  It  occurred 
in  a  perforating  wound  of  the  thorax,  and  was  fatal,  On  looking 
over  these  cases,  it  would  not  appear  that  wounds  of  either  the  foot, 
or  yet  of  the  lower  extremity,  show  a  greater  tendency  to  cause 
tetanus  than  others. 


144  SURGERY   OF   THE   CRIMEAN    WAR. 

Hughes,  a  private  of  the  44th  Regiment,  was  admitted 
into  the  general  hospital  on  the  18th  of  June.  In  the 
assault  on  the  Redan,  a  ball  had  entered  an  inch  below  the 
anterior  superior  spinous  process  of  the  right  ilium,  and, 
passing  downward  and  outward,  lodged  deeply  among  the 
muscles  of  the  thigh.  After  a  most  careful  and  prolonged 
examination,  its  position  could  not  be  ascertained,  and  it 
was  left,  in  the  hope  that  in  a  day  or  two  it  might  become 
defined,  or  that  it  might  perhaps  remain  altogether  without 
doing  harm.  There  was  no  fracture,  and  no  pain.  The 
case  was  treated  as  a  flesh  wound.  On  the  thirteenth  day, 
the  patient  for  the  first  time  complained  of  pain  behind  the 
great  trochanter  of  the  right  side,  and  the  presence  there  of 
deep  fluctuation  caused  me  to  make  an  incision.  A  con- 
siderable accumulation  of  pus  was  found,  and  in  the  sack  of 
this  collection  I  discovered  the  ball  much  flattened.  I 
freely  enlarged  the  wound,  so  that  all  retention  of  matter 
was  prevented.  Next  day  some  cloth  was  discharged  from 
this  opening.  On  the  seventeenth  day  his  manner  was 
changed.  He  was  irritable,  and  complained  of  his  wound. 
Pus  continued  to  flow  freely,  and  his  general  health  was 
unimpaired.  He  said  that  he  had  caught  cold,  and  "  that  it 
had  taken  him  in  the  jaws,"  which  were  a  little  stiff.  His 
bowels  being  costive,  I  ordered  him  a  purge,  and  an  embro- 
cation for  his  jaws.  I  had  not  at  this  time  any  suspicion  of 
the  impending  evil.  Next  day  I  found  that  his  bowels  had 
been  fully  moved,  and  that  most  offensive  dark-colored 
stools  had  resulted.  The  trismus  was  now  very  marked. 
The  masseters  were  hard  and  contracted,  like  clamps  of 
iron.  I  examined  the  wound,  and  further  enlarged  it.  A 
large  emollient  cataplasm  was  applied,  and  a  drop  of  croton 
oil  given  internally.  His  bowels  were  freed  of  much  more 
of  the  same  fetid  dejection  which  he  had  voided  formerly. 
In  the  afternoon,  when  rising  to  go  to  stool,  (which  he  in- 
sisted on  doing,)  he  had  a  violent  spasm  over  the  right  side 
of  the  body,  not  accompanied  with  any  pain.  From  this 


TETANUS.  145 

time  the  spasmodic  contractions  set  in,  recurring  at  certain 
intervals,  leaving  him  at  times  for  half  a  day,  but  always 
returning  till  his  death.  These  spasms  were  nearly  confined 
to  the  wounded  side,  and  affected  the  muscles  of  the  thigh 
most.  I  began  the  use  of  the  acetate  of  morphia  in  gr.  ij 
doses,  and  afterward  diminished  it  to  one  grain,  adminis- 
tered every  hour  till  lie  slept.  This  he  did  in  snatches 
during  the  succeeding  days,  waking  up  startled  if  any  one 
walked  near  his  bed.  Whenever  he  slept  for  an  hour  or  two, 
his  symptoms  were  markedly  alleviated.  When  he  slept, 
the  opium  was  intermitted  for  some  hours,  and  then  resumed. 
Only  on  the  first  day  did  he  exhibit  the  slightest  symptoms 
of  narcotism,  and  so  much  relief  did  he  experience  from  the 
use  of  the  drug  that  he  earnestly  asked  for  it  whenever  he 
was  a  few  hours  without  sleep.  He  always  denied  suffering 
any  pain,  though  from  the  way  in  which  the  corners  of  his 
mouth  were  drawn  upward  and  backward,  so  as  to  expose 
his  teeth,  and  the  manner  in  which  his  brow  was  knit,  he 
looked  as  if  he  was  in  extreme  agony.  There  was  one 
small  spot,  presenting  no  peculiarity  to  the  eye  or  touch,  on 
the  inner  side  of  the  knee,  and  another  on  the  ankle  of  the 
wounded  limb,  which  he  always  said  gave  him  much  pain. 
The  least  pressure  on  these  spots  always  caused  the  most 
violent  spasm.  He  frequently  expressed  his  astonishment 
at  the  limb  starting  in  the  way  it  did,  and  tried  in  vain  to 
prevent  it.  His  mind  remained  unaffected  till  near  his 
death,  when  he  became  dull  and  heavy  like  a  drunken  man. 
The  muscles  of  the  neck,  the  long  muscles  of  the  back,  as 
well  as  the  serratus  magnus  of  the  right  side,  and  the 
muscles  of  the  thigh  and  leg  of  the  same  side,  became  hard 
as  a  board,  particularly  during  the  transit  of  a  spasm.  So 
hard  and  contracted  were  they  that  when  we  had  occasion 
to  move  him  in  bed,  he  could  be  raised  like  a  log  of  wood, 
at  least  so  far  as  his  right  side  was  concerned.  His  abdo- 
men was  much  distended,  and  its  muscles  hard.  The 
clysters  which  were  administered  during  the  course  of  his 

13 


146  SURGERY    OF    THE   CRIMEAN    WAR. 

treatment  always  gave  him  much  relief  from  the  feeling  of 
"  bursting  "  of  which  he  so  often  complained.  He  lay  diag- 
onally in  the  bed,  his  wounded  limb  stretched  straight  out, 
and  the  other  drawn  up.  Latterly  he  suffered  from  a  severe 
pain,  which  continued  to  shoot  from  the  ensiform  cartilage 
to  his  spine,  and  also  from  intermitting  pains  in  his  right 
side.  For  a  couple  of  days  there  was  a  diminution  of  the 
discharge  from  the  wound,  but  ultimately  it  became  quite  re- 
established. His  skin  was  always  bathed  in  perspiration, 
the  excretion  having  a  most  pungent  and  offensive  smell. 
For  some  days  before  death  a  miliary  eruption  showed  itself 
over  the  upper  part  of  his  body.  His  pulse  was  slightly 
elevated  during  the  course  of  the  malady,  but  it  never 
reached  any  very  high  standard.  His  respirations  varied 
from  twenty-six  to  twenty-eight  per  minute.  A  very  viscid 
spittle,  which  he  was  always  trying  to  hawk  up,  gave  him 
much  annoyance.  He  had  retention  of  urine,  and  latterly 
suppression.  There  was  some  blood  mixed  with  his  urine 
for  a  couple  of  days. 

I  have  already  alluded  to  the  treatment  which  was  fol- 
lowed. Purgatives,  opium  given  freely,  at  first  combined 
with  camphor,  and  latterly  alone.  He  frequently  took  as 
much  as  fifteen  grains  of  opium  before  he  slept,  and  alto- 
gether he  must  have  consumed  a  great  quantity  of  that 
drug.  He  asked  for  fomentations  to  be  applied  to  his  limb, 
which  to  the  hand  felt  colder  than  its  fellow.  Their  appli- 
cation, he  said,  gave  him  relief.  His  ability  to  swallow 
semi-fluid  food  enabled  me  to  give  him  the  most  nutritious 
diet  I  could  devise,  along  with  wine.  With  intermissions 
and  exacerbations  his  fatal  malady  progressed.  A  spas- 
modic cough  was  added  to  his  other  ailments.  On  the 
afternoon  of  the  tenth  day  of  attack,  his  symptoms  greatly 
abated  for  some  hours,  and  while  he  was  conversing  with  a 
comrade,  he  was  seized  with  what  the  orderly  termed  "a  fit," 
vomited  some  dark  matter,  was  severely  convulsed,  so  that 
the  body  was  drawn  backward  and  to  the  right  side,  and 


TETANUS.  141 

before  I  reached  his  bedside  he  was  dead.  By  a  mistake 
of  the  hospital  sergeant,  no  post-mortem  examination  was 
got.  I  looked  hurriedly  at  the  wound  shortly  after  death. 
The  fascia  lata  was  much  lacerated,  and  the  parts  beneath 
were  sloughy. 

Barker,  a  private  in  the  38th  Regiment,  aged  20,  was 
admitted  into  the  general  hospital  in  camp  on  the  same  day 
as  the  last  patient,  June  18th.  A  ball  had  penetrated  his 
left  thigh  at  its  inner  and  lower  aspect,  and  lodged.  It 
could  not  be  found,  though  every  means  were  used.  Four 
days  afterward  it  was  felt  near  the  wound,  and  removed. 
By  the  28th  the  wound  was  looking  sloughy,  and  the  dis- 
charge was  thin  and  unhealthy.  He  complained  much  more 
than  was  usual  about  his  wound,  and  appeared  very  anxious. 
On  the  30th  I  noticed  some  twitching  of  the  limb  as  it  was 
being  dressed.  His  bowels  were  free,  but  he  complained  of 
sleeping  little  at  night.  The  wound  was  freely  enlarged, 
and  covered  with  a  poultice.  He  was  purged  with  croton 
oil  and  clysters.  He  grew  gradually  worse.  During  the 
two  succeeding  days,  the  spasms  were  very  decidedly  pro- 
nounced over  the  left  side.  He  described  them  himself  as 
proceeding  in  "flashes"  from  his  wound  to  the  spine,  and 
back  again.  Touching  the  limb,  and  particularly  the  sole 
of  the  foot,  immediately  aroused  the  most  violent  spasmodic 
contractions.  His  pulse  rose  to  92,  and  his  respirations  to 
29  per  minute.  He  did  not  complain  of  pain,  but  was 
greatly  distressed  by  a  thick  spit  which  clung  to  his  teeth, 
and  which  he  was  always  making  violent  attempts  to  expel. 
The  left  side  of  the  body  was  almost  alone  affected,  and  the 
spasms,  as  in  the  last  case,  drew  him  diagonally  backward, 
and  to  the  wounded  side.  He  had  no  trismus  for  the  first 
day,  but  afterward  it  became  marked.  He  always  said  that 
he  was  sure,  if  he  could  only  sleep,  he  would  be  all  right.  I 
brought  him  under  the  influence  of  chloroform,  and  while  its 
effects  continued,  the  spasms  were  relieved,  and  certainly  the 
pulse  and  respirations  were  reduced  in  frequency ;  but  so 


148  SURGERY    OF    THE    CRIMEAN    WAR. 

soon  as  he  awoke,  all  his  worst  symptoms  returned  in  undi- 
minished  vigor.  Having  seen  the  utter  futility  of  chloro- 
form to  relieve  the  spasms  permanently,  or  to  arrest  the  dis- 
ease, in  two  former  cases  at  home,  where  the  anesthetic  had 
been  fairly  tried;  and  having  many  wounded  to  attend  to, 
and  no  assistant  to  whom  I  could  intrust  the  exhibition  of 
the  anesthetic, — I  determined  to  abandon  it  and  trust  to 
opium.  This,  with  the  enemas,  nourishing  food,  and  local 
emollient  applications,  comprehended  all  the  treatment.  The 
symptoms  were  not  abated,  except  for  short  intervals,  and 
then  only  in  proportion  as  sleep  was  procured.  His  skin 
was  always  covered  with  an  odorous  perspiration.  The 
abdomen  got  distended  and  hard.  The  muscles  of  the  back 
were  markedly  hard  and  contracted,  particularly  on  the  left 
side.  The  left  leg  was  stretched  out  spasmodically,  every 
muscle  defined.  The  right  limb  was  drawn  up,  arid  he  lay 
across  the  bed.  The  wound  was  sloughy,  and  shreds  of 
fascia  escaped  with  the  discharge.  The  urine  became  scanty 
and  high  colored,  and  required  to  be  drawn  off  by  the  cathe- 
ter. Eventually  he  suffered  much  pain  in  the  left  groin  and 
calf  of  the  leg,  as  well  as  at  the  ensiform  cartilage.  When 
trying  to  raise  himself  on  his  elbow  on  the  fifth  day  of  the 
attack,  and  seventeenth  after  admission,  he  was  violently 
convulsed,  so  that  he  was  bent  greatly  backward;  he  put 
his  hand  to  his  throat  as  if  choking,  and  fell  back  dead. 

The  wound  was  found  to  be  lined  with  an  ashy  slough. 
The  bone  was  not  injured.  The  fascia  lata  was  much  torn, 
and  was  pierced  and  ulcerated  at  a  spot  on  the  anterior  and 
external  aspect  of  the  limb,  some  little  distance  from  the 
wound.  The  ball  had  evidently  penetrated  to  this  point. 
No  nerve  fibers  could  be  detected  near  the  wound.  The 
parts  in  the  neighborhood  were  sound.  The  brain  and  in- 
ternal organs  were  healthy.  The  lungs  were  only  slightly 
congested,  and  viscid  mucus  was  present  in  the  larger  tubes. 
The  spinal  canal  contained  a  good  deal  of  fluid  blood.  The 
cord  and  its  membranes  were  congested.  In  the  lower  cer- 


TETANUS.  149 

vical  and  upper  dorsal  region  the  substance  of  the  cord  was 
varicose — contracted  and  expanded  into  a  series  of  knots. 
There  was  no  other  pathological  appearance. 

On  looking  at  these  two  cases  in  connection,  the  curious 
parallelism  must  strike  one.  The  very  distinct  manner,  too, 
in  which  so  many  of  the  peculiar  symptoms  of  this  deadly 
disease  were  developed,  particularly  in  the  first  case,  was 
interesting.  Whether  opium,  which  appeared  to  act  so 
beneficially,  had  it  been  pushed  further,  so  as  to  produce  a 
more  decided  impression,  would  have  done  good,  is  a  ques- 
tion. I  believe  it  would  have  affected  the  result  but  little. 
The  similarity  between  the  wounds  in  these  two  cases,  the 
non-discovery  of  the  balls  for  some  days,  the  symptoms,  the 
season  of  the  year,  and  the  state  of  the  cord  in  the  last  case, 
were  all  interesting.  That  the  high  temperature  we  had  at 
that  period  had  much  to  do  with  the  production  of  the  dis- 
ease, is  not  certain ;  yet  three  of  the  six  cases  which  occurred 
in  front  appeared  during  a  period  of  extreme  heat.  In  one 
case  of  tetanus,  succeeding  an  injury  of  the  foot,  which  re- 
covered, chloroform  was  repeatedly  administered  for  pro- 
longed periods,  and  anodynes  applied  to  the  spine.  The 
particulars  of  this  case  are,  I  understand,  to  be  published  by 
the  surgeon  in  charge,  Dr.  Ward  of  the  17th  Regiment. 

As  to  treatment  we  are  yet  unfortunately  in  the  dark. 
Romberg  sums  up  his  review  of  the  question  thus  :  "  The 
results  of  treatment  amount  to  this,  that  wherever  tetanus 
puts  on  the  acute  form,  no  curative  proceeding  will  avail ; 
while  in  the  milder  and  more  tardy  form,  the  most  various 
remedies  have  been  followed  by  a  cure."  Larrey  trusted 
most  to  opium  and  camphor,  with  section  of  the  nerve  in 
cases  adapted  for  it.  On  reading  the  many  accounts  which 
have  been  given  of  cases  of  this  disease,  opium  and  chloro- 
form appear  decidedly  to  have  the  greatest  evidence  in  their 
favor. 

The  unpublished  records  of  the  Indian  campaigns  illus- 
trate to  a  great)  extent  the  remarkable  effect  which  uncx- 

13* 


150  SURGERY   OF   THE    CRIMEAN    WAR. 

traded  balls  seem  to  exercise  on  the  development  of  tins 
fatal  affection,  more  especially  when  they  lay  under  strong 
fasciaB,  as  in  my  cases.  In  India,  as  well  as  in  the  conti- 
nental campaigns,  amputation  at  the  shoulder  appears  to  be 
one  of  the  operations  most  frequently  followed  by  tetanus. 

Sudden  vicissitudes  of  temperature  have  been  always 
looked  upon  as  most  powerful  causes  of  tetanus,  especially 
the  change  from  a  hot  day  to  a  cold  and  damp  night,  which 
is  so  common  in  the  tropics.  So  it  was  after  the  battles  of 
Ferozepore  and  Chillianwallah,  when  the  wounded  lay  ex- 
posed to  very  cold  nights  succeeding  days  of  hard  work 
under  a  burning  sun.  Larrey  notices  the  same  circum- 
stances as  having  predisposed  to  the  disease  in  Egypt,  and 
in  the  German  campaign  of  1809.  After  Bautzen  the  ex- 
posure to  a  very  cold  night  produced  over  a  hundred  cases, 
and  after  the  battle  of  Dresden,  when  the  wounded  were 
placed  in  like  circumstances,  they  lost  a  very  large  number 
from  tetanus.  Baudens  gives  a  very  interesting  recital  from 
his  African  experience,  which  shows  the  influence  of  cold 
and  moisture  in  producing  this  disease.  Forty  slightly 
wounded  men  were  placed,  in  the  month  of  December,  and 
during  the  prevalence  of  a  northeast  wind,  in  a  gallery  on 
the  ground  floor,  which  was  open  to  the  north.  Fifteen  dif- 
ferent cases  of  tetanus  appeared  in  a  short 'time  —  among 
this  number  twelve  died.  The  remainder  were  removed  to 
a  more  sheltered  place,  and  there  were  no  more  attacked. 
The  exposure  after  the  Alma  might  have  been  expected  to 
produce  many  cases;  but  I  do  not  believe  that  many  re- 
sulted therefrom,  though  the  confusion  which  existed,  with 
regard  to  reports,  at  that  period,  makes  it  difficult  to  know 
what  was  the  real  effect  of  such  exposure  in  reference  to  this 
point. 

Opposite  extremes  of  temperature  appear  to  cause  simi- 
lar effects  in  this  most  curious  affection.  In  both  the  Indies, 
heat  is  looked  upon  as  a  most  powerful  predisposing  and 
exciting  cause,  and  idiopathic  tetanus  is  there  not  uncommon 


TETANUS.  151 

both  among  the  natives  and  the  European  troops,  while  in 
the  arctic  regions  it  is  even  more  frequent  and  fatal.  Sir 
Gilbert  Blane  tells  us,  that  out  of  810  wounded  men  who 
came  under  his  observation  in  the  West  Indies  in  1782, 
thirty  were  seized  with  tetanus  and  seventeen  died.  Dr. 
Kane's  experience  in  the  arctic  regions  shows  how  apt  ex- 
posure to  a  low  temperature  is  to  cause  it.  He  tells  ns 
that  while  most  of  his  party  were  more  or  less  affected,  he 
lost  two  men  from  "an  anomalous  spasmodic  affection  allied 
to  tetanus,"  and  that  all  his  dogs  perished  from  a  like  cause. 
The  great  cold,  exposure,  and  frost-bites,  which  were  sus- 
tained in  the  Crimea  during  the  first  winter,  were  followed 
by  fewer  cases  of  tetanus  than  we  might  have  expected, 
though  I  suspect  more  cases  appeared  than  we  have  any 
record  of. 

I  am  ignorant  of  the  total  number  of  cases  which  have 
occurred  in  the  French  hospitals;  but  of  five  cases  with  the 
history  of  which  I  was  familiar,  and  which  appeared  about 
the  same  period  in  the  hospitals  at  Constantinople,  one  fol- 
lowed compound  fracture  of  the  thigh  ;  two,  wounds  of  the 
foot;  and  one,  a  penetrating  wound  of  the  chest  in  a  Zouave, 
who,  after  recovery,  was  allowed  to  visit  the  city,  where  he 
remained  drunk  for  three  days  :  he  was  seized  with  tetanus 
on  his  return,  and  died  in  48  hours.  The  French  trust 
mostly  to  opium  in  the  treatment,  and  report  favorable  re- 
sults from  its  use  ;  though  I  suspect,  from  what  I  have  heard, 
that  not  a  few  cases  of  simple  trismus  were  inadvertently 
classed  by  them  under  the  more  formidable  disease  of  tetanus. 

I  have  been  put  in  possession  of  the  particulars  of  some 
cases  which  occurred  in  India,  where  amputation  was  had 
recourse  to  in  tetanus.  They  all  ended  fatally  without 
relief,  though  if  performed  early,  before  the  peripheral  irri- 
tation had  time  to  set  up  much  centric  disturbance,  this  step 
would  certainly  appear  to  promise  good  results,  in  so  far  as 
the  cause  being  removed,  local  applications  to  the  spine 


152  SURGERY    OF    THE    CRIMEAN    WAR. 

would  have  a  better  chance  of  succeeding  in  allaying  the 
excited  action.* 

Hospital  gangrene  was  not  common  in  the  East.  During 
the  first  winter  it  prevailed  a  good  deal  in  a  mild  form  at 
Scutari,  but  it  never  became  either  general  or  severe.  It 
did  not  appear  to  pass  from  bed  to  bed,  but  rose  sporadi- 
cally over  the  hospitals.  It  frequently  attacked  the  openings 
both  of  entrance  and  exit,  but  occasionally  seized  on  one 
only,  showing  apparently  a  predilection  for  the  wound  of 
exit.f  At  times  it  showed  itself  only  in  part  of  a  wound, 
and  spread  in  one  direction  alone.  It  was  never  severe,  and 
was  invariably,  as  far  as  I  saw,  of  the  variety  designated 
"  ulcerous"  by  Delpech,  and  "phagedsena  gangrenosa"  by 
Boggle.  In  many  cases  the  best  designation  for  it,  as  it 
appeared  with  us,  would  have  been  the  old  one  of  "  putrid 
degeneration."  The  earliest  symptom  was  pain  in  the  part, 
which  sometimes  preceded  the  ulcerative  process  by  a  couple 
of  days.  The  edges  of  the  wound  did  not  swell  up,  but 
remained  thin  as  they  were  undermined.  The  pain  generally 
continued  during  the  process  of  destruction.  It  appeared 
chiefly  in  the  lower  extremities,  and  in  wounds  whose  prog- 
ress toward  cure  had  been  for  some  time  stationary.  It 
seldom  burrowed  far  into  the  intermuscular  tissue,  but  con- 
fined its  ravages  to  the  surface  and  the  circumference  of  the 
wound.  I  never  saw  any  marked  gastric  disturbance  attend 
it.  If  it  attacked  the  wounds  of  those  already  laboring 
under  fever,  it  appeared  to  aggravate  the  fever. 

The  abominable  state  in  which  the  barrack  hospital  at 
Scutari  was  during  its  early  occupation  may  well  have 

*  Larrey  amputated  successfully  in  several  cases,  and  speaks 
highly  of  it  in  those  instances  which  are  adapted  for  it;  but  after 
Toulouse  it  failed  completely  in  our  army,  though  tried  extensively. 

f  Dr.  Taylor  thought  in  India  that  gangrene  more  commonly  ap- 
peared in  the  wounds  occasioned  by  grape  and  canister.  I  cannot 
say  I  observed  this  confirmed  in  the  East,  although  it  seems  very 
probable  it  should  be  so. 


GANGRENE.  153 

caused  an  outbreak  of  hospital  gangrene  among  the  broken- 
down  men  who  lay  so  thickly  around  the  doors  of  the  offen- 
sive latrines ;  but  I  cannot  say  that  I  noticed  any  greater 
tendency  to  its  appearance  at  these  places  than  in  any  other 
portion  of  the  hospital.  The  corridors  presented,  I  think, 
the  greatest  number  of  cases.  Whenever  it  appeared,  the 
patients  were  isolated,  and  sent  into  wards  set  apart  for  the 
treatment  of  the  disease.* 

Nitric  acid,  applied  locally,  and  the  exhibition  of  the 
tincture  of  the  muriate  of  iron  internally,  in  half-drachm 
doses,  three  times  daily,  proved  to  be  the  most  efficacious 
means  of  stopping  it  as  it  appeared  in  our  hospitals.  The 
local  nature  of  the  complaint  was  universally  recognized, 
and  local  measures  relied  on  for  its  relief.  The  application 
of  the  escharotic  not  only  to  the  edges  of  the  sore,  but  also 
to  the  healthy  tissues,  at  a  little  distance  round  the  margin, 
secured  by  far  the  best  means  of  employing  the  remedy.  A 
barrier  of  lymph  appeared  to  be  thus  thrown  up  around, 
which  prevented  the  spread  of  the  peculiar  inflammatory  or 
destructive  action  in  the  skin  and  cellular  tissue  to  which  it 
was  always  confined.  The  attendant  fever  was  uncertain  in 
its  development;  sometimes  it  preceded,  sometimes  it  accom- 
panied, and  sometimes  it  followed  the  local  outbreak.  Often 
there  was  little  if  any  constitutional  disturbance,  and  occa- 
sionally the  fever  was  of  a  low  typhoid  type.  The  most 
generous  diet  was  always  necessary,  fur  though  it  may  be 
true,  as  was  the  case  in  the  Peninsula,  that  an  antiphlogistic 

*  How  far  this  segregation  into  separate  wards  is  a  good  plan,  I 
am  disposed  to  doubt.  That  the  malignancy  of  the  disease  is  there- 
by increased,  and  the  danger  to  the  other  inmates  of  the  hospital 
enhanced,  has  been  the  opinion  generally  held  on  the  adoption  of 
such  measures.  If  each  patient  was  taken  outside  of  the  hospital, 
and  placed  in  a  tent  by  himself,  it  would  be  the  most  successful  way 
of  treating  such  cases.  In  an  outbreak  of  this  kind,  wooden  huts 
would  be  found  most  excellent  hospitals,  as  I  know  from  experience 
elsewhere. 


154  SURGERY    OF   TIIE   CRIMEAN   WAR. 

treatment  is  at  times  necessary,  it  can  be  so  only  in  strong, 
healthy  men,  who  derived  the  disease  from  infection.  With 
us  the  depression  of  the  powers  of  life  was  so  marked,  and 
appeared  to  exercise  so  strong  an  influence,  as  predisposing 
to  its  outbreak,  that,  in  place  of  lowering  remedies,  the  most 
strengthening,  including  stimulants,  and,  above  all,  fresh  air, 
were  absolutely  required,  and  were  alone  of  any  use. 

Those  who  had  suffered  in  camp  from  diarrhoea,  and 
whose  strength  had  thus  been  much  reduced,  more  especially 
those  whose  constitutions  were  strongly  impregnated  with 
scurvy,  were  most  liable  to  be  attacked;  and,  in  all  our 
cases,  so  far  as  I  saw,  the  development  of  the  disease 
resulted  from  a  lowered  general  health  more  than  from 
specific  causes.  It  was,  in  many  cases,  a  veritable  "child 
of  the  typhus."  The  peculiar  dark  hue  of  the  face,  spoken 
of  by  writers,  was  not  common,  though  it  was  occasionally 
seen;  but  the  disagreeable  smell  and  the  rounded  shape  of 
the  sore  were  almost  always  present.  The  introduction  of 
disinfectants  into  our  military  hospitals  has  done  much  to 
prevent  the  prevalence  of  this  disease,  which  committed 
such  ravages  during  the  Peninsular  war.* 

The  French  suffered  most  dreadfully  from  hospital  gan- 
grene in  its  worst  form.  The  system  they  pursued,  of 
removing  their  wounded  and  operated  cases  from  the  camp 
to  Constantinople  at  a  very  early  date,  the  pernicious  char- 
acter of  the  transit,  the  crowding  of  their  ships  and  hos- 
pitals, all  tended  to  produce  the  disease,  and  to  render  it 
fatal  when  produced.  Many  of  their  cases  commenced  in 
camp,  but  the  majority  arose  in  the  hospitals  on  the  Bos- 
phorus,  where  the  disease  raged  rampant.  In  the  hospitals 
of  the  south  of  France  it  also  prevailed,  and,  from  what  M. 
Lallour,  surgeon  to  the  "Euphrate"  transport,  tells  us  in 
his  paper  on  the  subject,  it  must  have  committed  great 

*  See  paper  by  Staff-Surgeon  Boggle,  in  the  first  part  of  the  third 
volume  of  the  Transactions  of  the  Medico-Chirurgical  Society  of 
Edinburgh. 


GANGRENE.  155 

ravages  in  their  ships,  from  one  of  which,  he  says,  sixty 
bodies  were  thrown  over  during  the  short  passage  of  thirty- 
eight  hours  to  the  Bosphorus.  With  them  the  disease  was 
the  true  "contagious  gangrene,"  and  attacked  not  only 
open  wounds,  hut  cicatrixes,  and  almost  every  stump  in  their 
hospitals.  They  employed  the  actual  cautery,  after  the 
manner  of  Delpech  and  Pouteau,  witli  apparent  success,  to 
arrest  it.  The  perchlorate  of  iron,  charcoal,  the  tincture  of 
iodine,  lemon-juice,  etc.,  they  employed  as  adjuvants.  In 
both  the  French  and  Russian  hospitals,  gangrene  was  often 
combined  with  typhus,  and  in  such  cases  the  mortality  was 
fearful. 

In  the  Crimea,  during  the  heat  of  the  summer  of  1855, 
after  the  taking  of  the  Quarries  and  the  assault  on  the  great 
Redan  in  June,  not  a  few  amputations  of  the  thigh  were 
lost,  from  moist  gangrene  of  a  most  rapid  and  fatal  form. 
In  the  case  of  a  few  who  lived  long  enough  for  the  full 
development  of  the  disease,  gangrene  in  its  most  marked 
features  became  established ;  but  most  of  the  men  expired 
previous  to  any  sphacelus  of  the  part — overwhelmed  by  the 
violent  poison  which  seemed  to  pervade  and  destroy  the 
whole  economy.  This  form  of  the  disease  occurred  in  four 
cases  under  my  own  charge,  in  men  who  had  had  a  limb 
utterly  destroyed  by  round  shot  or  grape.  In  all  the  knee- 
joints  were  crushed,  the  collapse  was  deep  and  prolonged, 
and  the  operation  performed  primarily  in  the  middle  third 
of  the  thigh.  Three  of  the  four  were  of  very  intemperate 
habits.  All  these  cases  took  place  about  the  same  time,  at 
midsummer,  when  many  other  similar  cases  appeared  in 
camp.  The  wards,  though  full,  were  not  overcrowded,  and 
could,  from  their  construction,  be  freely  ventilated.  The 
weather  was  sultry,  and  cholera  was  in  the  camp.  The 
atmosphere  was  surcharged  with  electricity,  and  the  dreaded 
sirocco  prevailed.  Wounds  generally  assumed  an  unhealthy 
aspect  for  days  when  this  pestilential  wind  blew.  The  cases 
of  all  those  who  died  in  my  wards  seemed  to  be  doing  per- 


156  SURGERY    OF    THE    CRIMEAN    WAR. 

fectly  well  up  to  sixteen  hours,  at  the  farthest,  before  death. 
Three  of  them  were  seized  on  the  eighth  clay  after  ampu- 
tation, just  as  suppuration  was  being  established.  The 
fourth  died  on  the  fifth  day.  The  seizure  and  consequent 
symptoms  were  identical  in  them  all.  In  recording  one 
case  I  relate  all.  During  the  night  previous  to  death, 
the  patient  was  restless,  but  did  not  complain  of  any  par- 
ticular uneasiness.  At  the  morning  visit,  the  expression 
seemed  unaccountably  anxious,  and  the  pulse  was  slightly 
raised.  The  skin  was  moist,  and  the  tongue  clean.  By 
this  time  the  stump  felt,  as  the  patient  expressed  it,  heavy 
like  lead,  and  a  burning,  stinging  pain  had  begun  to  shoot 
through  it.  On  removing  the  dressings,  the  stump  was 
found  slightly  swollen  and  hard,  and  the  discharge  had 
become  thin,  gleety,  colored  with  blood,  and  having  masses 
of  matter  like  gruel  occasionally  mixed  with  it.  A  few 
hours  afterward,  the  limb  would  be  greatly  swollen,  the 
skin  tense  and  white,  and  marked  along  its  surface  by  prom- 
inent blue  veins.  The  cut  edges  of  the  stump  looked  like 
pork.  Acute  pain  was  felt.  The  constitution,  by  this  time, 
had  begun  to  sympathize.  A  cold  sweat  covered  the  body, 
the  stomach  was  irritable,  and  the  pulse  weak  and  frequent. 
The  respiration  became  short  and  hurried,  giving  evidence 
of  the  great  oppression  of  which  the  patient  so  much  com- 
plained. The  heart's  action  gradually  and  surely  got 
weaker,  till,  from  fourteen  to  sixteen  hours  from  the  first  bad 
symptom,  death  relieved  his  sufferings.  All  local  and  con- 
stitutional remedies  which  could  be  thought  of  were  equally 
powerless :  nothing  could  relieve  the  system  from  the  weight 
which  seemed  to  crush  it,  or  enable  it  to  support  the  severe 
burden.  Strong  stimulants  were  the  only  remedies  which 
appeared  to  retard  the  issue  for  a  moment.  Post-mortem 
examination,  instituted  shortly  after  death,  showed  the 
tissues  of  the  limbs,  and  in  many  cases  those  of  the  internal 
organs  also,  to  be  filled  with  gas,  and  loaded  with  serous 
fluid.  The  vessels  leading  from  the  stump  were  healthy, 
and  in  only  one  case  had  there  been  any  actual  mortification 


ERYSIPELAS — FROST-BITE.  157 

previous  to  death.  The  intestines,  in  two  of  the  four  cases, 
were  much  diseased.  Was  the  cause  which  gave  rise  to 
this  affection  referable  to  "weakness  or  defective  powers  of 
action,"  arising  from  the  patients'  bad  state  of  general  health, 
or  "excessive  irritability  or  disposition  to  act,"  from  their 
being  of  intemperate  habits?  or  was  it  "excessive  irritation 
or  excitement  to  act,"  arising  from  the  severity  of  the  injury 
sustained  ?  After  the  taking  of  the  city,  in  September,  the 
same  form  of  disease  again  appeared,  especially  among  the 
Russians  who  had  been  operated  on;  and  was  so  deadly 
that  in  no  case,  which  I  could  hear  of,  did  recovery  follow.* 

Erysipelas  was  latterly  rarely  seen  in  our  hospitals. 
Several  cases  which  appeared  in  my  own  wards  readily 
yielded  to  treatment.  At  Scutari  there  were  a  good  many 
cases,  at  the  time  when  the  men  were  most  depressed  by 
their  hardships ;  but  it  was  seldom  virulent. 

The  troops  suffered  greatly,  during  the  first  winter  which 
they  passed  in  the  Crimea,  from  frost-bite.  Death  not 
unfrequently  followed  on  the  injuries  it  occasioned.  The 
severity  which  marked  these  lesions  did  not  arise  from  the 
degree  of  cold,  as  the  temperature  was  never  so  low  as  of 
itself  to  cause  the  severe  results  produced,  but  rather  from 
the  depressed  vital  power  of  the  soldiers,  who  could  not 
resist  the  effects  of  a  degree  of  cold  which  would  have  little 
injured  them  if  they  had  been  in  rude  health.  The  practice, 
which  was  nearly  universal,  of  sleeping  in  their  wet  boots, 
aided  greatly  in  causing  the  results.  This  custom  arose 
from  the  fear  that,  if  the  boots  were  put  off,  they  could  not 
be  drawn  on  again.  They  were  retained,  and  thus  the  feet, 

*  Dr.  Taylor,  in  bis  report  on  the  2(.)th  Regiment,  to  which  inter- 
esting document  reference  has  been  already  made,  says:  "It  is  to 
be  observed,  as  illustrating  the  possibility  of  gangrene  infection  lying 
dormant  for  some  days,  or  of  fomites  of  the  disease  hanging  about 
the  clothing  of  the  men,  that  wounded  men  discharged  fit  to  rejoin 
their  regiments  were  in  several  instances  returned  from  camp  to 
hospital  with  hospital  gangrene." 

14 


158  SURGERY   OF    THE    CRIMEAN    WAR. 

kept  for  a  long  time  at  a  low  temperature,  with  the  circula- 
tion retarded,  at  length  lost  their  vitality — slowly,  but  all 
the  more  surely  on  that  account. 

The  scorbutic  poison,  too,  with  which  the  men  were 
drenched,  predisposed  strongly  to  the  action  of  the  cold, 
and  it  was  even  at  times  difficult  to  say  how  much  of  the 
destructive  result  was  due  to  the  one  cause  or  the  other. 
During  the  first  winter  the  frost-bites  were  much  more  severe 
than  during  the  second,  and  much  more  difficult  to  manage, 
from  the  more  depressed  vitality  of  the  patients.  I  referred 
in  a  previous  chapter  to  that  peculiar  effect  caused  in  the 
feet  by  the  union  of  scurvy  and  frost-bite,  to  which  it  is  so 
difficult  to  give  a  name. 

Tetanic  symptoms  resulted  in  a  few  cases  from  frost-bite 
injuries  of  the  feet.  The  French  suffered  more  than  we  did. 
In  their  hospitals  a  limb  might  be  seen  sphacelated  half 
way  to  the  knee.  Uncontrollable  diarrhoea  was  a  common 
complication  in  such  cases,  and  invariably,  according  to  M. 
Legouest,  caused  death.  Scrive  (Mem.  de  Med.  et  de  Chir. 
Milit.,  vol.  xvii.)  tells  us  that  on  the  21st  January,  1855, 
with  the  thermometer  at  5°,  they  had  2500  cases  of  frost- 
bite admitted  into  their  ambulances,  of  whom  800  died,  and 
that  at  that  period  no  operation  succeeded,  so  that  "it  was 
necessary  to  abstain  from  operating."  M.  Legouest  says  he 
found,  in  treating  his  cases  at  Constantinople,  that  a  solution 
of  sulphate  of  iron  formed  the  best  dressing,  but  of  its  use 
I  had  no  experience.  To  obtain  the  separation  of  the  scars, 
and  regulate  the  subsequent  granulation  on  general  princi- 
ples, was  what  had  chiefly  to  be  attended  to.  Soothing 
applications  appeared  to  be  the  best  in  the  cases  which  I 
had  an  opportunity  of  watching. 

It  is  not  easy  to  decide  whether  or  not  we  should  operate 
in  such  severe  cases  as  sometimes  occur,  when  half  the  foot, 
for  example,  or  the  lower  part  of  the  leg,  is  implicated. 
Either  step  is  somewhat  hopeless;  but  if  the  part  be  un- 
questionably dead,  arid  of  such  a  nature  and  size  as  not  to 
be  separable  by  "the  parsimonious  industry  of  nature," 


FROST-BITE.  159 

without  so  long  a  period  of  irritation  and  suppuration  as 
will  be,  in  all  probability,  fatal ;  or,  if  the  presence  of  a 
large  gangrenous  surface  endangers  not  only  the  patient 
himself,  but  also  his  neighbors  in  the  ward ;  or  if  there  is 
hospital  gangrene  present  in  the  hospital,  to  an  attack  of 
which  the  long  open  state  of  his  wound  will  so  much  expose 
him,  then  it  is  a  fair  question  to  consider,  whether  amputa- 
tion is  not  a  lesser  evil  than  waiting.  The  success  which 
follows  will  depend  much  on  the  state  of  the  patient's 
general  health,  and  on  the  condition  of  the  parts ;  as,  unless 
a  clear  line  of  separation  "be  formed,  and  the  parts  above  be 
tolerably  healthy,  the  irritation  occasioned  by  removal  will 
be  sure  to  cause  gangrene  in  the  stump — at  least  so  it  was 
in  the  Eastern  hospitals,  in  all  the  cases  in  which  I  knew  it 
tried.  I  never  heard  of  any  amputation  performed  under 
the  above  circumstances  succeed  during  the  first  winter,  but 
several  such  occurred  during  the  second.  Operating  at 
some  distance  beyond  the  spread  of  the  disease  was  gener- 
ally found  safer  than  at  the  place  of  division  between  the 
dead  and  living  parts. 

Any  wounds  from  frost-bite  are  peculiarly  difficult  to  heal. 
Many  suffered  from  their  effects  for  months  after  getting  to 
France  or  England. 

The  removal  of  bone  from  the  toes  or  fingers,  however 
black  and  apparently  dead,  and  though  only  attached  by  the 
most  slender  connection,  was  certain  to  cause  a  great  amount 
of  irritation,  which  sometimes  became  most  alarming.  This 
result  was  probably  as  much  due  to  the  enfeebled  state  of 
the  patient  as  to  the  cause  fur  which  the  operation  was  per- 
formed. Complete  non-interference  during  every  stage  of 
treatment,  the  use  of  the  mildest  dressings,  the  removal  of 
parts  only  when  quite  disjoined,  proved  the  best  line  of  pro- 
cedure. I  never  saw  any  other  followed,  either  in  our  hos- 
pitals or  in  those  of  the  French,  without  there  being  ample 
cause  to  regret  it.  Any  roughness  even,  in  dressing  these 
injuries,  endangered  the  appearance  of  gangrene,  on  the 
verge  of  which  they  always  seemed  to  hover. 


CHAPTER  VII. 

INJURIES    OF    THE    HEAD. 

From  April  1,  1855,  to  the  end  of  the  war,*  the  returns  show  a  total  of 
030  cases  of  gunshot  wounds  of  the  head  attended  by  contusion  merely, 
more  or  less  severe,  and  8  deaths  are  recorded  among  these  cases.  Of 
gunshot  fracture  without  known  depression,  61  cases  appear,  and  2.3 
deaths  therefrom.  Of  cases  of  fracture  and  depression,  followed  by 
sensorial  disturbance,  74  cases  are  mentioned,  and  53  deaths  therefrom; 
while  of  wounds  penetrating  the  cranium,  67  cases  and  67  deaths  are 
recorded.  Of  19  cases  in  which  the  skull  was  perforated,  all  died. 
The  trephine  was  employed  28  times,  and  of  these  cases  24  ended 
fatally.f 

MR.  GUTHRIE  has  said,  with  much  truth,  that  "injuries  of 
the  head  affecting  the  brain  are  difficult  of  distinction, 
doubtful  in  character,  treacherous  in  their  course,  and,  for 
the  most  part,  fatal  in  their  results."  Of  all  the  accidents 
met  with  in  field  practice,  these  are,  beyond  doubt,  the 
most  serious,  both  directly  and  remotely — the  most  confusing 
in  their  manifestations,  and  least  determined  in  their  treat- 
ment, although  they  have  engaged  the  attention  of  the 
master-minds  of  all  ages  and  countries,  from  the  time  of  the 
old  surgeon  of  Cos  down  to  the  present  day.  Such  men  as 

*  The  returns  are  not  complete  before  the  date  specified. 

f  Alcock  reports  28  cases  of  fracture  of  the  skull  from  gunshot, 
and  22  deaths.  Meniere  gives  10  penetrating  wounds  by  balls,  all 
of  whom  died  —  half  on  the  day  of  admission.  In  the  medical 
reports  from  India  I  find  only  9  cases  so  detailed  as  to  be  useful. 
They  were  all  penetrating  wouuds,  and  6  of  them  died.  Lente,  in 
his  statistics  of  the  New  York  Hospital,  mentions  128  cases  of  frac- 
ture of  the  skull,  attended  by  death  in  106  instances.  Several  of 
these  were  fractures  of  the  base,  and  none  by  gunshot. 
(160) 


INJURIES   OF   THE    HEAD.  161 

Petit,  Quesney,  Ledran,  Pott,  Dease,  Heister,  Cooper,  Du- 
puytren,  Bell,  Velpeau,  Larrey,  Brodie,  and  a  host  of  other 
honored  names,  have  thrown  the  light  of  their  large  experi- 
ence and  commanding  genius  on  the  subject;  even  minor 
points  connected  with  it  have  been  made  the  theme  of  whole 
libraries,  and  of  innumerable  discussions  in  the  first  medical 
societies  of  the  world ;  still  there  is  no  accident  which  the 
surgeon  takes  charge  of  with  more  fear  and  hesitation,  as  in 
no  class  of  cases  does  he  feel  so  much  the  mystery  which 
surrounds  and  guards  our  life :  for  while  in  some  cases 
death  follows  the  most  trivial  injury,  in  others  a  vast 
amount  of  destruction,  and  even  removal  of  brain-matter, 
causes  little  if  any  disturbance. 

In  war,  injuries  of  the  head  of  all  descriptions  are  pre- 
sented to  us.  Those  by  contre-coup,  especially  such  as  im- 
plicate the  base  of  the  skull,  are  certainly  rare;  but  these 
also  at  times  do  occur.  The  comparative  rarity  of  this  form 
of  injury  in  military,  as  compared  with  civil  practice,  is  pos- 
sibly accounted  for  by  the  less  frequent  occurrence  of  such 
accidents  as  are  fitted  to  injure  the  base,  and  by  the  fact 
that  war- projectiles  seldom  present  a  surface  so  large  as  to 
supply  those  conditions  which  the  experiments  of  Bichat 
would  show  are  necessary  to  produce  fracture  of  the  skull 
by  counter-stroke.  It  is,  however,  by  no  means  true  that 
the  "punctured  fracture,"  as  it  is  termed,  is  the  only  species 
-of  injury  to  which  soldiers  in  the  field  are  liable.  Shell, 
grape,  and  sword  wounds  of  the  skull  afford  examples  of 
almost  every  kind  of  fracture. 

The  nature  of  the  injury  inflicted  by  a  ball  striking  the 
skull  will  depend  chiefly  on  the  angle  of  incidence,  and  the 
velocity.  The  character  of  the  ball,  too,  has  more  to  do 
with  the  matter  than  is  generally  supposed.  If  the  direc- 
tion of  the  projectile  be  very  oblique  to  the  surface,  and  if 
the  force  be  exhausted  at  the  moment  of  contact,  then  the 
injury  may  be  very  slight — a  mere  contusion  of  the  soft  parts 

14* 


162  SURGERY   OF    THE    CRIMEAN    WAR. 

or  of  the  bone.*  If  the  force  be  greater,  then  the  peri- 
cranium may  be  much  injured,  the  bone  considerably  bruised, 
or  slightly  fractured  throughout  its  whole  thickness,  or  in 
one  or  other  of  its  tables  separately — the  fracture  of  the 
inner  sometimes  taking  place  without  any  apparent  injury 
of  the  outer. |  Further,  the  brain  may  be  injured  as  well  as 
its  case,  when  the  blow  is  yet  more  direct  or  severe.  This 
injury  may  be  merely  of  such  a  nature  as,  John  Bell  well 
says,  "we  choose  to  express  our  ignorance  of  by  calling  it  a 
concussion,"  which  may  pass  away,  doing  little  harm,  or 
which  may  be  followed,  at  an  uncertain  interval,  by  enceph- 
alic inflammation,  and  compression  from  effusion. 

Again,  the  effect  of  a  ball  "  brushing"  over  the  skull  may 
be  such  that,  while  the  bone  is  not  fractured,  the  vessels 
between  the  skull  and  the  dura  mater  may  be  ruptured,  or 
the  longitudinal  sinus  may  be  opened,  as  occurred  in  one 
case  in  the  Crimea,  and  which  has  been  related  by  the  sur- 
geon of  the  19th  Regiment,  in  which  it  was  observed.  J 

A  remarkable  instance,  showing  how  completely  the  skull 
may  be  destroyed  by  a  glancing  shot,  without  the  scalp  being 
implicated,  occurred  at  the  Alma.  A  round  shot,  "en 
ricochet,"  struck  the  scale  from  an  officer's  shoulder,  and 
merely  grazed  his  head  as  it  ascended.  Death  was  instant- 
aneous. The  scalp  was  found  to  be  almost  uninjured  ;  but 
so  completely  smashed  was  the  skull  that  its  fragments  rat- 
tled within  the  scalp  as  if  loose  in  a  bag.  The  condition  of 
the  brain  was,  unfortunately,  not  examined. 

*  Stromeyer  supposes  that  the  (lunger  of  a  grazing  shot  arises  very 
much  from  pygemia.  Inflammation  of  the  bone  follows  the  injury, 
the  veins  of  the  diploe  become  implicated,  and  thus  pus  enters  the 
system. 

f  Preparation  No.  2-594  in  the  museum  of  Fort  Pitt  exhibits  'the 
manner  in  which  part  of  the  outer  table  of  the  skull  may  be  removed 
by  gunshot  injury,  and  yet  the  inner  wholly  escape;  and  No.  2511 
shows  that  the  inner  table  may  be  "considerably  depressed,  without 
corresponding  depression  of  the  cuter." 

J  See  Lancet,  vol.  i.,  1855. 


INJURIES   OF    THE    HEAD.  1G3 

A  bullet,  from  the  great  force  with  which  it  impinges 
upon  the  skull,  and  the  concentration  of  that  force  on  a 
small  point,  causes  a  fracture  dissimilar  to  most  of  those 
which  are  met  with  in  civil  practice.  It  is  this  concentra- 
tion of  the  force  on  a  small  point  which  renders  fractures 
from  a  ball  so  dangerous,  as  the  bone  is  driven  deeply  into 
the  brain,  and  the  splintering,  especially  of  the  inner  table, 
is  often  very  severe. 

The  greater  splintering  of  the  inner  than  of  the  outer 
tahle,  by  a  ball  penetrating  the  skull  from  without,  is  ex- 
plicable on  the  principles  which  interpret  the  difference 
between  the  wounds  of  entrance  and  of  exit  in  the  soft  parts, 
and  which  I  before  explained  by  reference  to  a  series  of  ex- 
periments on  planks  of  wood.  The  greater  support  afforded 
to  the  outer  than  to  the  inner  table,  by  the  parts  lying  be- 
hind it,  and  the  diminished  force  of  the  ball  as  it  passes 
through  each,  sufficiently  account  for  the  difference.  An 
observation  of  Erichsen's  on  the  point  quite  supports  this 
explanation.  He  has  noticed  that  the  characters  of  the 
apertures  in  the  two  tables  were  reversed,  in  an  instance  in 
which  a  man  had  committed  suicide  by  shooting  himself 
through  the  head  from  the  mouth — the  ball  thus  passing 
from  within  outward.  In  a  case  from  Bagieu,  related  by 
Sebatier,  the  same  circumstance  is  noted  in  a  similar  in- 
stance.* The  preparation  in  the  Fort  Pitt  museum,  num- 
bered 2592,  illustrates  the  same  thing.  In  that  case,  a  ball 
had  perforated  the  head,  thus  making  two  holes,  the  one  in 


*  Lnrrey  thinks  that  in  young  persons  a  ball  may  enter  the  skull, 
leaving  a  hole  less  than  itself,  from  the  yielding  and  subsequent 
closure  of  the  osseous  fibres.  This  is  not  observed  in  the  old,  in 
whom  the  bone  is  more  brittle,  and  splinters.  A  case  is  related 
by  Dr.  Longmore,  of  the  10th  Regiment,  in  the  second  volume  of  the 
Lancet  for  1855,  by  which  it  would  appear  that  a  ball  may  split, 
part  outer  the  skull,  and  yet  the  bone  recover  its  level  by  its  re- 
siliency BO  completely  as  to  leave  no  trace  of  the  passage  of  the  part 
of  the  ball  which  entered. 


164  SURGERY    OF    TUE   CRIMEAN    WAR. 

the  front  and  the  other  in  the  lateral  and  posterior  part. 
The  inner  table  of  the  orifice  of  exit  is  regular,  while  the 
outer  "is  torn  up  to  an  extent  much  larger  than  the  ball." 
An  appreciation  of  these  distinctions  is  of  much  use  to  the 
medical  jurist. 

The  character  of  the  fracture  caused  in  the  skull  by  the 
large  conical  balls  is,  I  am  inclined  to  believe,  considerably 
different  from  that  occasioned  by  the  round  ball.  The  destruc- 
tion by  them  of  the  outer  table  always  appeared  to  me  much 
greater  than  by  the  round  ball ;  and  thus,  perhaps,  it  is  that 
the  size  of  the  openings  in  the  two  tables  is  more  equalized 
in  the  wounds  occasioned  by  the  former  than  by  the  latter 
species  of  missile.  So  it  comes,  I  think,  that  the  true  "punc- 
tured fracture"  is  less  seen  now  in  military  practice  than  it 
was  formerly.  I  state  this,  however,  with  much  hesitation, 
as  it  would  require  a  larger  number  of  observations  than  I 
possess  to  substantiate  it. 

Balls  striking  the  head  otherwise  than  perpendicularly  to 
its  surface,  or  impinging  against  one  of  its  angles,  may  be 
split — part  entering  the  skull  and  part  flying  off.  This  oc- 
curred in  cases  which  have  been  related  by  Mr.  Wall,  of  the 
38th  Regiment,  and  by  Dr.  Longmore,  of  the  19th.*  Such 
instances  are  not  uncommon  in  war.  Larrey,  following  the 
half  which  entered,  removed  it  by  counter-opening  from  the 
back  part  of  the  head.  One  half  of  a  split  ball  has  been  seen 
to  lodge  between  the  tables  of  the  skull.  The  whole  ball, 
also,  has  been  found  thus  placed,  especially  at  the  fore  part 
of  the  head.  There  are  various  instances  on  record  of  a 
round  ball  penetrating  the  outer  paries  of  the  frontal  sinus, 
without  injuring  the  inner  table  ;  but  I  believe  that  no  such 
instances  will  ever  be  found  where  a  conical  ball  is  used.  It 
not  only  penetrates,  but  generally  perforates,  the  skull,  and 
almost  always  proves  fatal. 

The  most  dreadful  injuries  of  the  head  seen  in  war  are 

*  See  Addenda  to  the  last  edition  of  Mr.  Gutbrie's  Commentaries. 


INJURIES   OF   THE    HEAD.  165 

those  occasioned  by  shell.  Although  rarely,  yet  it  does  at 
times  happen  that  this  missile  cuts  open  the  scalp  only,  or 
merely  grazes  the  bone  ;  yet  it  more  frequently  occurs  that 
large  masses  of  the  skull  are  driven  by  it  into  the  brain. 
Examples  will  be  afterward  given  of  shell  wounds  of  the 
head.  One  of  the  most  ghastly  injuries  of  the  skull  which 
I  ever  witnessed  was  caused  by  a  fragment  of  shell.  The 
whole  frontal  bone  was  driven  deeply  into  the  brain,  yet, 
strange  to  say,  the  poor  sufferer  lived  for  twenty-four  hours 
after  such  a  wound. 

Sword-cuts  sometimes,  as  is  well  known,  slice  away  parts 
of  the  skull.  These  portions  will,  at  times,  readhere,  if  im- 
mediately applied.  In  the  museum  of  the  Val  de  Grace 
several  remarkable  examples  of  this  are  to  be  seen.*  I  had 
under  my  charge,  after  the  fall  of  Sebastopol,  a  Russian  sol- 
dier who  had  received  such  a  wound,  although  the  bone  was 
not  entirely  detached  in  his  case.  The  left  parietal  bone 
was  cleft  so  as  to  be  almost  separated.  He  would  allow  no 
one  to  touch  his  wound  except  a  comrade.  His  recovery 
was  complete,  the  brain  never  showing  any  tendency  to  pro- 
trude, although  quite  visible  throughout  the  whole  extent 
of  the  wound.  I  saw  this  Russian  in  the  interior,  after  peace, 
in  perfect  health.  The  comparative  rarity  of  hernia  of  the 
cerebral  substance  after  sword,  as  compared  with  gunshot 
wounds,  is  very  remarkable. 

Cuts  from  a  blunt  sword  are  peculiarly  dangerous,  from 
the  extensive  splintering  and  depression  of  the  inner  table 
which  so  commonly  results. ")• 

*  Sebatier  relates  several  such  cases  at  length,  from  Leaultd, 
IMattuT,  and  others. 

f  That  trephining  does  little  good  in  these  cases,  is  illustrated  by 
the  practice  of  beast.-,  who  had  under  his  charge  many  men  wounded 
by  the  "hunger,"  which  played  so  important  a  part  in  all  the 
street  frays  of  his  time.  Four  of  the  seven  cases  he  trephined  died; 
while  in  the  only  four  instances  in  which  he  seems  not  to  have  inter- 
fered, recovery  followed.  In  a  case  which,  although  not  caused  by 


166  SURGERY    OF    THE   CRIMEAN    WAR. 

One  of  the  most  remarkable  circumstances  connected  with 
gunshot  wounds  of  the  head  is  that  they  are  not  more  uni- 
versally followed  by  concussion,  or  that  the  symptoms  of 
concussion,  when  produced,  are  often  so  temporary  in  dura- 
tion. I  have  been  frequently  told  by  men  who  had  received 
wounds  of  considerable  severity  that  they  experienced  merely 
feelings  of  passing  "weakness"  when  struck.  Symptoms 
of  concussion,  however,  more  generally  follow  severe  blows ; 
and  the  gradual  and  almost  insensible  manner  in  which  this 
state  passes  into  one  of  compression  or  of  inflammation,  and 
that  into  consequitive  compression,  forms  one  of  the  most 
treacherous  and  dangerous  features  of  these  cases.  It  is 

a  sword,  was  yet  a  fracture  of  a  similar  description,  and  which  oc- 
curred lately  in  the  Royal  Infirmary  of  this  city,  under  Mr.  Lyon, 
the  recovery  was  probably  owing  to  the  non-interference  with  the 
injured  bone,  further  than  the  removal  of  loose  portions.  A  man 
aged  19  was  admitted  on  the  28th  of  July.  He  had  been  struck  on 
the  head  by  the  handle  of  a  crane,  and  the  whole  scalp  round  and 
round  the  head,  with  the  exception  of  the  anterior  part,  separated. 
The  bone  was  fractured  into  small  pieces,  to  the  extent  of  four  inches 
by  one  and  a  hall',  over  the  right  side  of  the  head— the  fracture 
slanting  obliquely  over  the  orbit.  He  suffered  much  from  the  shock 
when  admitted,  but  replied  to  questions  put  to  him.  Bony  spiculae 
were  driven  into  the  right  eye,  the  right  malar  bone  was  broken,  and 
the  frontal  sinuses  opened.  The  loose  and  broken  bones  were  re- 
moved, when  the  brain  was  found  to  be  laid  bare  to  the  extent  of 
three  inches,  and  the  dura  mater  destroyed.  Low  diet,  purging,  and 
cold  locally,  were  the  remedies — the  scalp  being  carefully  laid  down, 
and  the  spiculas  removed  from  the  eye.  The  fractured  bones  were 
not  interfered  with,  further  than  the  removal  of  perfectly  loose  por- 
tions. A  week  after  admission,  the  brain  began  to  protrude  by  the 
oprning  in  the  skull,  but  by  gentle  compression  it  soon  receded,  and 
the  patient  made  a  rapid  recovery,  interrupted  only  by  a  slight  hem- 
orrhage from  a  vessel  in  the  scalp,  which  was  easily  suppressed. 
The  wound  completely  healed — the  bone  being  bridged  over  by  dense 
tissue,  and  the  cicatrix  sunk  in  a  narrow  furrow,  the  pulsations  of 
the  brain  remaining  visible.  His  pulse  never  exceeded  eighty.  The 
supra-orbital  ridga  remains  much  below  its  proper  position,  and  the 
right  eye  is  destroyed. 


INJURIES   OP    THE    HEAD.  167 

evidently  a  matter  of  much  importance  to  those  who  advo- 
cate trephining,  in  certain  circumstances,  to  be  able  to  dis- 
tinguish accurately  between  these  variable  conditions  ;  as  to 
operate  in  cases  of  mere  concussion,  or  in  a  state  of  inflam- 
mation, would  be  murder,  yet  how  to  discriminate  is  a  prac- 
tical puzzle  in  many  cases — especially  in  a  large  number 
which  fall  to  be  treated  in  the  field,  when  the  period  of  their 
coming  under  observation  is  very  uncertain,  and  when  no 
account  can  be  got  of  their  history  or  early  symptoms.  It 
requires  but  the  most  cursory  reading  of  surgical  works  to 
determine  that  the  utmost  confusion  has  always  existed  be- 
tween these  various  pathological  conditions;  even  Sir  Astley 
Cooper,  with  all  his  habitual  clearness,  has  not  unfrequently 
confounded  them.  It  is  little  wonder  that  it  should  be  so, 
as  their  clear  distinction  is  found  only  in  books,  and  their 
interdependence  and  mutual  reactions,  as  well  as  the  uncer- 
tainty of  their  respective  manifestations,  all  contribute  to 
deceive  "the  pride  of  our  penetration,"  and  lead  us  into 
error. 

The  absence  of  any  ascertainable  cause,  and  the  threaten- 
ing symptoms  which  were  present,  in  the  following  case  of 
concussion,  interested  me  a  good  deal  at  the  time.  In  for- 
mer days  it  would  have  been  infallibly  ascribed  to  the  wind 
of  a  ball.  Quin,  a  private  in  the  18th  Royal  Irish,  sud- 
denly fell  down  unconscious,  in  the  advance  on  the  Redan, 
early  in  the  morning  of  the  18th  of  June.  He  never  could 
tell  how  this  happened,  not  being  aware  of  any  injury.  He 
was  brought  into  my  ward  insensible  a  few  hours  afterward. 
His  symptoms  were  those  of  severe  concussion.  The  surface 
of  his  body  was  cold,  his  respiration  was  slow  and  regular, 
and  his  pupils  were  contracted.  No  injury  could  either  then 
or  afterward  be  discovered.  Warmth,  and  an  enema  of  the 
arom.  sp.  of  ammonia,  helped  to  restore  him  to  conscious- 
ness, after  he  had  vomited.  He  continued,  however,  for 
some  hours,  like  a  man  half  drunk.  Reaction  was  so  violent 
as  to  call  for  bleeding,  cold  to  the  head,  antimonials,  and 


168  SURGERY    OF    THE    CRIMEAN    WAR. 

purging,  to  moderate  it.  Some  days  afterward  he  suddenly 
became  delirious,  with  injected  eyes,  one  pupil  being  con- 
tracted and  the  other  a  little  dilated.  He  complained  much 
of  his  head,  which  he  afterward  said  had  felt  all  the  time  as 
if  strongly  bound  by  a  cord.  There  was  never  any  paraly- 
sis or  subsequent  unconsciousness.  By  free  purging,  shaving 
the  head,  applying  cold,  restricting  him  to  very  meager  diet, 
and,  latterly,  by  the  use  of  blisters  to  the  nape  of  the  neck, 
he  completely  recovered,  though  for  about  a  month  he  suf- 
fered from  severe  headache,  double  vision,  and  a  pulse 
unusually  slow,  and  little  changed  on  assuming  the  erect 
posture. 

The  danger  occasioned  by  gunshot  wounds  of  the  head 
will  depend  much  on  the  part  struck.  At  some  places  the 
ball  is  more  apt  to  glance  off  than  at  others,  while  the  strong 
processes  of  bone,  the  situation  of  blood  vessels,  and  the 
apparently  greater  necessity  to  life  of  some  parts  of  the  brain 
than  others,  introduce  many  elements  into  the  calculation  of 
the  result.  Notwithstanding  all  this,  however,  the  curious 
eccentricities  which  characterize  these  injuries — the  slight 
disturbance  created  by  some  which,  to  all  appearance  and 
experience,  are  ten  times  more  severe  than  others  that  prove 
fatal — upset  our  preconceived  opinions  ;  and,  while  they 
puzzle  us  to  account  for  the  difference,  they  prove  the  truth 
of  Liston's  aphorism,  that  "no  injury  of  the  head  is  too 
slight  to  be  despised  or  too  severe  to  be  despaired  of." 

Generally  speaking,  it  appears  tolerably  certain  that 
wounds  of  the  side  of  the  head,  especially  anterior  to  the 
ear,  are  the  most  dangerous  to  life ;  and  that  a  descending 
scale  will  give  the  following  order — the  fore  part,  the  vertex, 
and  the  upper  part  of  the  occipital  region,  the  last  being 
decidedly  the  least  dangerous.  Remarkable  exceptions  to 
this  graduating  scale  of  danger  do,  however,  occur. 

There  are,  at  the  same  time,  other  circumstances  besides 
the  seat  and  nature  of  the  injury  which  influence  the  result. 
The  age  of  the  patient  is,  perhaps,  the  most  important  of 


INJURIES   OF    THE    HEAD.  169 

these.  With  children  and  young  persons,  the  same  gravity 
by  no  means  attaches  to  the  prognosis  of  head  injuries  as 
to  similar  accidents  occurring  to  the  old.  Mr.  Gnthrie  has 
well  observed,  that  in  the  accounts  of  wonderful  escapes  and 
successful  operations  on  the  head,  the  subjects  have  been,  in 
general,  below  puberty.  The  temperament  of  the  patient, 
his  excitability,  his  social  condition,  as  giving  rise  to  more 
or  less  anxiety  regarding  the  result  of  his  case;  the  means 
there  are  of  carrying  out  his  treatment  as  to  quiet,  isola- 
tion, etc.;  the  place  where  he  is  treated,  whether  in  the  hos- 
pital of  a  populous  city,  where  the  results  of  such  cases  are 
usually  so  fatal,  or  in  the  country,  where  so  much  more  can 
be  accomplished, — all  these  are  important  items  in  forming 
an  opinion  regarding  injuries  of  the  cranium. 

Gunshot  wounds  of  the  head,  being  chiefly  compound, 
enable  us  to  ascertain,  with  tolerable  precision,  the  amount 
of  injury  which  has  been  inflicted;  and  if  it  be  thought 
necessary  to  employ  any  means  to  elevate  depressed  bone,  we 
can  do  so  with  less  hesitation  than  if  the  scalp  were  unhurt; 
as,  if  it  be  true,  what  some  of  our  best  surgeons  tell  us,  that 
the  danger  of  inflammation  in  the  membranes  is  increased  by 
opening  the  integuments,  then  this  source  of  danger  cannot 
be  charged  to  us.*  Such  facilities  should  not,  however, 
make  us  less  careful  in  our  proceedings. 

As  to  the  use  of  the  trephine — the  cases,  and  time  for 
its  application  —  less  difference  of  opinion,  I  believe,  exists 
among  the  experienced  army  surgeons  than  among  civilians; 
and  I  think  the  decided  tendency  among  them  is  to  indorse 
the  modern  "treatment  by  expectancy,"  and  to  avoid  opera- 
tion except  in  rare  cases.  In  this,  I  believe,  they  judge 
wisely ;  for,  when  we  examine  the  question  carefully,  we  find 
that  there  is  not  one  single  indication  for  having  recourse  to 
operation,  which  cannot,  by  the  adduction  of  pertinent  cases, 

*  This  source  of  danger  is  particularly  dwelt  upon  by  Stromeyer, 
Larrey,  and  Dupuytren. 

15 


170  SURGERY   OF    THE    CRIMEAN    WAR. 

be  shown  to  be  often  fallacious ;  while,  if  we  turn  to  author- 
ities for  advice,  we  find  that  not  a  great  name  can  be  ranged 
on  one  side  which  cannot  be  balanced  by  as  illustrious  on 
the  other. 

Simple  contusion,  without  fracture  or  depression,  caused 
the  old  surgeons  to  "set  on  the  large  crown"  of  a  trephine 
in  order  to  prevent  future  danger.  Fracture,  although  not 
accompanied  by  depression,  or  any  other  untoward  symptom, 
called  for  the  trephine  in  the  practice  of  the  Pott  school;* 
while  many,  even  now,  would  operate  to  cure  the  local  pain 
which  so  often  remains  persistent  at  the  place  of  injury. 
Other  surgeons,  again,  discarding  and  condemning  all  this, 
say  we  should  trephine  only  when  there  is  depression  ;  but 
the  amount  of  depression  which  demands  it,  each  interprets 
according  to  his  own  fancy.  None  knows  so  well  as  the 
army  surgeon  how  very  considerable  a  depression  may  exist, 
especially  at  some  parts  of  the  head,  without  any  injury  to 
the  brain  ;  nor  how  innumerable  are  the  cases  in  which  great 
depression  has  been  present,  without  causing  harm  at  any 
subsequent  period  of  the  patient's  life. 

A  musket-ball  being  the  wounding  cause,  would  appear  to 
some  a  sufficient  reason  why  the  trephine  should  be  applied, 
however  slight  may  be  the  lesion.  "  We  should  always  tre- 
phine," says  Qnesney,  "in  wounds  of  the  head  caused  by 
fire-arms,  although  the  skull  be  not  fractured."  "All  the  best 
practitioners,"  says  Pott,  "have  always  agreed  in  acknowl- 
edging the  necessity  of  perforating  the  skull  in  the  case  of  a 
severe  stroke  made  on  it  by  gunshot,  upon  the  appearance  of 
any  threatening  symptom,  even  though  the  bone  should  not  be 
broken  ;  and  very  good  practice  it  is."  Boyer  and  Percy  are 

•;f  This  most,  false  doctrine  was  that  also  taught  by  the  Academy  of 
Surgery  and  the  leading  men  in  France,  till,  by  the  able  writings 
and  practice  of  Bichat  and  Default,  it  was  in  a  great  measure 
rejected;  however,  it  is  from  the  writings  of  M.  Malgaigne,  more 
perhaps  than  from  those  of  any  other,  that  this  question  has  received 
its  true  interpretation. 


INJURIES   OF   THE    HEAD.  171 

equally  urgent  when  a  ball  has  caused  the  injury.  However, 
"the  experience  of  war,"  to  which  Quesney  appeals  in  con- 
firmation of  his  opinion,  now-a-days  completely  condemns 
the  practice,  whatever  it  may  have  done  formerly. 

Further,  "symptoms  of  compression"  setting  in  early  or 
late,  are  laid  down  by  others  as  urgently  demanding  the  re- 
moval of  the  bone.  "No  injury, "says  John  Bell,  "requires 
operation  except  compression  of  the  brain,  which  may  arise 
either  from  extravasated  blood,  or  from  depressed  bone,  or 
matter  generated  within  the  skull."  But,  unfortunately,  we 
can  seldom  diagnose  the  existence  of  compression  with  any 
amount  of  certainty,  when  it  sets  in  early,  and  experience 
teaches  us  that  each  and  all  of  those  signs  which  are  said 
to  indicate  it  may,  under  appropriate  treatment,  pass  away 
without  interference;  especially  when  these  symptoms  appear 
early,  and  often  also  when  they  set  in  late.  Compression 
too,  when  it  appears  at  a  late  date,  if  it  arise,  as  it  generally 
does,  from  the  presence  of  pus,  is  well  known  to  be  seldom 
relieved  by  trephining.  Dease  first  showed  how  it  was  that 
the  matter  was  commonly  deeply  placed  or  diffused  in  such 
cases;  and  the  instances  in  which  it  has  been  found  on  the 
surface,  or  evacuable  by  such  a  bold  maneuver  as  the  well- 
known  thrust  of  Dupuytren,  are  exceedingly  rare. 

Some  authors,  again,  would  have  us  trephine  only  when 
the  symptoms  of  compression  are  severe,  go  on  increasing  in 
severity,  and  have  continued  for  some  time;  yet,  even  under 
such  circumstances,  "recovery  not  seldom  disappoints  our 
fears,  and  mortifies  us  by  our  success."* 

But,  finally,  it  is  to  those  surgeons  who  instruct  us  to  oper- 
ate when  certain  pathological  conditions  exist,  which  they 
carefully  define,  but  which  experience,  unfortunately,  tells  us 

*  See,  especially,  as  good  instances  of  this,  Quesney's  first  and 

second  oi>^ci-v;;tinns.      In  the  first,   the  ^tujjor  and  delirium  bir-trd 

months,  .-Hid  in  the  olher.  it  h;id  continued  :il.«o  tor  a  h-n^fhi'ncd 

time.     Stromeyer,  by  antiphlogistic  remedies  alone,  saved  several  in 

•which  the  "stupor  had  lasted  1'or  weeks  together." 


172  SURGERY    OF    THE    CRIMEAN    WAR. 

do  not  often  manifest  themselves  by  any  recognizable  signs, 
that  we  are  chiefly  indebted  for  useful  directions  to  assist  us 
in  cases  of  difficulty.  What  good  can  it  do  to  say  you  must 
trephine  when  the  internal  table  is  splintered  more  extensively 
than  the  external,  when  effusion  has  taken  place  on  the  brain, 
and  so  on,  when  we  have  often  no  means  of  knowing  when 
these  conditions  exist,  or  when  we  are  fully  aware  that  they 
have,  each  and  all,  been  present,  and  that  to  a  very  consider- 
able extent,  without  any  of  their  appropriate  signs  being 
manifest? 

But  to  refer  more  particularly  to  those  cases  which  fall  to 
the  charge  of  the  military  surgeon.  There  are  three  classes 
to  which  the  trephine  is  still  occasionally  applied :  1st,  frac- 
ture with  depression,  before  symptoms  have  appeared;  2d, 
fracture  with  depression,  attended  immediately  with  signs 
said  to  indicate  compression;  3d,  fracture  with  or  without 
depression,  followed  at  a  late  period  by  symptoms  evidenc- 
ing compression. 

It  is  with  reference  to  the  first  class  of  cases  that  "the 
experience  of  war  "  is  most  useful  and  most  decided.  There 
are,  I  believe,  very  few  surgeons  of  experience  in  the  army 
now-a-days  who  approve  of  "preventive  trephining."*  It 
may  be  said  in  our  time  to  be  a  practice  of  the  past — a  prac- 
tice to  be  pointed  at  as  a  milestone  which  we  have  left  be- 
hind. A  very  large  number  of  instances  fell  under  my  own 

*  "That  blood  may  be  effused,"  says  Guthrie,  "and  matter  may 
be  formed,  is  indisputable,  even  under  the  most  active  treatment;  but 
that  any  operation  by  the  trephine  will  anticipate  and  prevent  these 
evils,  cannot  be  conceded  in  the  present  state  of  our  knowledge  ;  and 
the  rule  of  practice  is  at  present  decided,  that  no  such  operation 
should  be  done  until  symptoms  supervene  distinctly  announcing  that 
compression  or  irritation  of  the  brain  has  taken  place.  It  is  argued 
that,  when  these  symptoms  do  occur,  it  will  be  too  late  to  have  re- 
course to  the  operation  with  success;  this  may  be  true,  as  such  cases 
must  always  be  very  dangerous,  but  it  does  not  follow,  and  it  never 
has  been,  nor,  indeed,  can  it  be,  shown  that  the  same  mischief  would 
not  have  taken  place  if  the  operation  had  been  performed  early." 


INJURIES   OF   THE    HEAD.  173 

notice  in  the  East,  in  which,  by  the  use  of  evacuants  and 
quiet,  and  the  absence  of  all  operative  interference,  a  perfect 
and  uninterrupted  recovery  followed  these  injuries,  even  when 
the  bone  was  very  extensively  depressed.  Every  surgeon  in 
the  array  can  recount  many  such  cases.  If  any  patients 
were  lost  from  not  having  been  operated  on,  I  never  saw  any 
of  them  ;  but  I  do  know  of  some  patients  who  died  because 
they  were  subjected  to  operation. 

The  wonderful  manner  in  which  the  brain  accommodates 
itself  to  pressure  has  been  remarked  in  all  times,  and  the 
crania  in  our  museums  show  how  extensive  the  depression 
may  be,  'and  yet  the  brain  escape  injury,  or  in  which, 
although  the  central  mass  may  be  pressed  upon  or  hurt, 
recovery  has  yet  followed.  In  the  cases  of  fracture  with 
depression  which  have  presented  themselves  to  me  during 
the  war,  the  symptoms  and  the  amount  of  depression  have 
seldom  been  in  correspondence.*  But,  in  order  to  attain 

*  liennen,  ill  particular,  refers  to  a  case  in  which  bone  was  de- 
pressed hi  "a  funnel  shape,"  to  the  extent  of  an  inch  and  a  half, 
and  yet  the  patient  lived  in  comfort  for  thirteen  years.  Stromeyer 
mentions  forty-one  cases  of  fracture  with  depression  from  gunshot, 
and  in  many  of  which  it  is  probable  that  the  brain  was  injured, 
although  that  could  not  be  ascertained.  Of  these  cases  only  seven 
died,  and  one  of  these  perished  by  typhus  fever.  All  the  rest  recov- 
ered, and  in  only  one  case  was  there  any  operative  interference, 
although  signs  of  secondary  compression  appeared  in  several.  The 
antiphlogistic  treatment,  carefully  carried  out,  was  alone  adhered  lo. 
Seutin,  who  was  at  the  head  of  the  medical  service  at  Antwerp  when 
it  was  besieged  in  1832,  gives  us  the  results  of  his  experience  in  the 
following  words:  "  Far  be  it  from  us  the  pretension  to  decide  the 
question  which  divides  practitioners  of  the  greatest  merit:  we  will 
not  take  up  the  defense  of  either  the  one  side  or  the  other,  but  we 
think  that  it  is  necessary  to  limit  to  a  small  number  the  cases  of 
fracture  which  demand  the  operation  of  trephining — nn  operation 
which  often  causes  grave  accidents,  and  the  success  of  which  is 
always  very  uncertain.  The  following  facts,  collected  at  the  siege  of 
Antwerp,  prove,  in  an  evident  manner,  that  in  the  greater  number 
of  cases  of  fracture  of  the  skull,  when  they  are  simple,  or  even 

15* 


174  SURGERY    OF    THE    CRIMEAN    WAR. 

favorable  results,  it  is  absolutely  necessary  that  great  atten- 
tion be  paid  to  the  management  of  the  patient,  of  which  I 
shall  speak  more  afterward. 

Those  who  have  read  with  attention  the  records  of  cam- 
paigns must  have  often  been  struck  with  the  numerous  in- 
stances which  are  there  recounted  where  men,  with  gunshot 
depressed  fractures  of  the  skull,  have  recovered  in  circum- 
stances which  forbade  any  attention  being  paid  to  them. 
During  hurried  retreats  and  forced  marches,  this  has  often 
occurred.  When  privation  was  added  to  the  absence  of  all 
surgical  interference,  these  happy  results  were  the  more 
marked.  In  Larrey,  Guthrie,  Ballingall,  and  in  the  Indian 
reports,  many  illustrations  of  this  are  found.  Dease,  also, 
long  ago  recorded  the  observation  that  "  those  patients  who 
neglected  all  precepts,  and  lived  as  they  pleased,  just  did  as 
well  as  those  who  received  the  utmost  attention;"  at  which 
we  need  not  wonder,  when  we  remember  in  what  "the 
utmost  attention"  consisted.  Thus  it  would  seem  as  if 
severe  fatigue,  irregular  and  it  might  be  intemperate  diet, 
are  less  injurious  to  men  with  fracture  of  the  skull  than  the 
probings,  pickings,  and  trephinings  which  form  the  more 
orthodox  and  approved  practice.  Deputy-Inspector  Taylor, 

comminuted,  or  with  slight  depression,  we  can  often  abstain  from 
operating.  It  was  by  immediate  incisions,  and  taking  care  to  extract 
all  underlying  fragments,  and  employing  mild  dressings,  and  using 
antiphlogistics  and  revulsives  that  we  have  been  able  to  avoid  the 
use  of  the  trephine.  It  was  by  such  methodic  treatment  that  we 
have  obtained  such  happy  results  in  the  case  of  the  large  number  of 
'wounded  which  have  fallen  under  our  charge." 

The  reunion  of  bone  which  has  been  depressed,  with  the  rest  of 
the  skull,  is  well  illustrated  by  preparations  2506,  2507,  and  2512, 
in  the  museum  at  Fort  Pitt.  In  that  numbered  2512,  "part  of  the 
squamous  portion  of  the  temporal,  and  part  of  the  parietal  bone,'' 
is  depressed  three-quarters  of  an  inch  from  the  original  level,  and 
the  diameter  of  the  fracture  is  about  three  inches,  yet  the  patient 
recovered  perfectly,  and  lived  as  an  officer's  servant  for  three  years, 
when  he  died  of  fever. 


INJURIES    OP    THE    HEAD.  175 

in  his  able  report  on  the  wounded  of  the  29th,  in  India,  after 
referring  to  several  wonderful  recoveries  from  gunshot  de- 
pressed fracture  of  the  skull,  very  appropriately  remarks, 
that  he  attributed  the  fortunate  results  in  these  cases  "to 
the  system  adopted  of  very  cautious  meddling  with  the 
wound."* 

*  I  cannot  deny  myself  the  pleasure  of  recording  a  case  which 
lately  occurred  in  the  practice  of  Dr.  George  Willis,  of  Baillieston, 
in  the  neighborhood  of  Glasgow,  which  is  remarkable  for  the  extent 
of  the  lesion,  the  period  when  the  trephine  was  applied,  and  the  per- 
fect and  rapid  cure.  William  Donald,  aged  3G,  a  pit-sinker,  a  man 
of  intemperate  habits,  but  of  strong  frame,  was  struck  on  the  i!()th 
of  June  last,  at  four  o'clock  in  the  afternoon,  on  the  left  side  of  the 
head,  by  a  piece  of  stone  weighing  thirty  pounds,  which  had  been 
thrown  high  into  the  air  by  the  explosion  of  a  mine  he  had  con- 
structed in  the  prosecution  of  his  work.  He  immediately  fell  down 
insensible,  and  was  put,  in  that  condition,  into  a  cart,  and  conveyed 
to  his  hDuse,  which  lay  two  and  a  half  miles  from  the  place  where 
he  met  with  the  accident.  In  about  half  an  hour  from  the  moment 
he  was  struck,  and  before  he  reached  home,  he  slowly  regained  con- 
sciousness, and  on  his  arrival  at  his  own  door  he  was  able  to  walk 
into  the  house  with  assiskince.  He  was,  however,  unable  to  speak. 
Dr.  Willis  saw  him  about  this  time,  and  found  a  semilunar  wound, 
about  nine  inches  long,  extending  over  the  left  side  of  the  head,  and 
curving  over  the  ear.  The  flap  of  the  scalp  hung  down  over  his  ear, 
and  a  clot  of  blood  covered  the  bone.  On  clearing  away  this  mass 
of  effused  blood,  the  bone  was  found  to  be  comminuted  and  depressed 
in  an  irregular  crescentic  shape,  to  the  extent  of  four  inches  long  by 
two  broad.  It  was  driven  downwai'd  to  the  depth  of  a  quarter  of  an 
inch,  and  comprised  part  of  the  frontal  and  a  portion  of  the  parietal 
bones.  The  flap  of  the  scalp  was  cleaned  and  replaced,  and  cold 
applied.  Nothing  else  was  done  that  evening.  His  pupils  remained 
unaffected  at  all  times,  and  his  pulse  never  was  much  disturbed,  but 
at  the  evening  visit  his  mouth  was  found  drawn  to  the  left  side. 
Next  morning  at  ten  o'clock  the  speechlessness  remained,  but  no  new 
symptoms  were  added.  The  fractured  bones  were  so  firmly  impacted 
that  they  could  not  be  removed  without  the  use  of  the  trephine, 
which  was  accordingly  applied  at  the  upper  part  of  the  fracture,  and 
when  a  piece  of  bone  was  thus  removed,  the  rest  were  easily  got  at  and 
withdrawn.  The  dura  mater  was  entire,  and  rose  immediately  in  iho 


176  SURGERY   OF   THE   CRIMEAN    WAR. 

More  difficulty  exists  as  to  the  treatment  of  the  second 
class  of  cases  referred  to  before,  viz.,  those  in  which  there  is 
fracture  with  depression,  attended  immediately  by  those 
signs  which  are  usually  said  to  indicate  compression. 

Compression  is  undoubtedly  the  evil  against  which  the 
trephine  is  generally  employed.  But  yet,  with  all  that  has 
been  said  on  the  subject,  in  books  and  lectures,  I  question 
whether  we  are  sufficiently  acquainted  with  the  nature,  seat* 
or  signs  of  compression,  to  warrant  us  in  undertaking,  at 

wound.  At  each  pulsation  of  the  brain  blood  flowed  from  between 
the  skull  and  the  membrane.  Whenever  the  depressed  fragments 
were  removed,  the  tongue  could  be  protruded,  which  before  the  oper- 
ation it  could  not.  It  projected  to  one  side.  The  speech  did  not 
return.  The  scalp  was  replaced  and  fixed;  he  was  purged  and  put 
on  low  diet,  and  kept  quiet,  cool,  and  in  the  dark.  By  night  he  had 
again  lost  all  power  over  his  tongue,  but  recovered  it  next  morning, 
and  from  thai  period  his  convalescence  went  on  so  rapidly  that  in 
three  weeks  his  wound  had  completely  cicatrized ;  he  never  had  an 
uneasy  feeling,  and  returned  in  perfect  health  to  his  work  withjn 
six  weeks  of  the  period  when  he  met  with  the  accident.  I  saw  him, 
by  the  courtesy  of  Dr.  Willis,  some  time  afterward.  He  told  me  he 
never  had  had  a  headache  since  the  day  of  his  dismissal,  although  he 
acknowledged  to  have  been  repeatedly  drunk.  The  cicatrix  was  firm, 
and  considerably  sunk,  and  the  brain  pulsations  could  be  obscurely 
felt  at  one  corner  of  the  wound. 

*  I  have  myself  known  the  trephine  applied,  in  two  cases,  to  in- 
juries on  the  vertex  of  the  head,  when  the  compressing  fracture 
existed  at  the  base.  Are  we,  in  cases  of  doubt,  to  proceed  as  Heister 
directs?  "Sometimes  it  is  impossible,"  he  says,  "to  discover  the 
particular  part  of  the  cranium  which  is  injured;  the  patient  in  the 
mean  time  being  afflicted  with  the  most  urgent  and  dangerous  symp- 
toms. In  these  cases  it  will  be  necessary  to  trepan  first  on  the  right 
side,  then  on  the  left  side  of  the  head,  afterward  upon  the  forehead, 
and  lastly  upon  the  occiput,  and  so  all  round  until  you  meet  with  the 
seat  of  the  disorder."  Even  in  recent  times  the  same  practice  has 
been  recommended  by  Benjamin  Bell,  who  says  we  must,  "form  the 
first  perforation  in  the  most  inferior  part  of  the  cranium  in  which  it 
can  with  any  propriety  be  made,  and  proceed  to  perforate  every 
accessible  part  of  the  skull  till  the  cause  of  the  compression  is  dis- 
covered " 


INJURIES    OF    THE    HEAD.  17 1 

an  early  period  at  any  rate,  an  operation  of  so  serious  a 
description,  as  all  recorded  experience  has  shown  trephin- 
ing  to  be,  without  more  reliable  and  more  clearly-defined 
evidence  of  its  presence  than  is  commonly  thought  to  denote 
it.  Symptoms  which,  by  the  dicta  of  books,  were  unquestion- 
ably those  of  compression,  have  passed  off,  in  the  experience 
of  every  one,  under  a  treatment  of  which  non-interference 
was  the  most  important  item ;  while  in  other  cases  such 
large  quantities  of  fluid — blood  and  pus — have  been  found, 
post-mortem,  on  the  brain,  as  all  recorded  experience  tells 
us  should  have  caused  a  compression  which  yet  never  ap- 
peared. We  find  cases  on  record  in  which  it  is  evident  that 
traumatic  encephalitis  was  mistaken  for  compression,  and 
the  skull  trephined ;  and  in  some  such  instances  good  effects 
have  followed,  evidently  from  the  local  bleeding,  which,  in 
several  of  these  cases,  was  considerable;  or,  perhaps,  from 
the  preliminary  incising  of  the  pericranium,  which  we  know 
has,  in  some  cases,  succeeded  of  itself  in  removing  symp- 
toms analogous  to  those  caused  by  compression.* 

Blood  rapidly  effused  may  cause  early  compression,  which 
we  know  often  passe^  off  as  the  effusion  is  absorbed  ;  or 
mere  congestion,  the  result  of  injury,  may  give  rise  to  the 
same  symptoms,  and  be  allayed  by  depletion ;  yet,  if  we 
trephine  early,  we  may  have  only  such  conditions  to  contend 
with. 

*  Dease's  third  case  and  that  of  M.  A.  Farnham  in  Guthrie  (p. 
243  of  the  last  edition)  are  good  and  parallel  illustrations  of  this. 
In  both  there  were  signs  of  pressure  on  the  brain.  In  Dease's  case 
there  were  all  the  signs  of  pus  having  formed.  In  Guthrie's,  the 
paralysis,  etc.  were  the  orthodox  symptoms  of  pressure.  Both  were 
trephined,  and  in  both  the  dura  mater  and  bone  were  found  perfectly 
sound.  Both  were  immediately  relieved  of  their  symptoms,  and  re- 
covered, although  one  nearly  "died  of  the  doctor."  In  the  one  "the 
scalping,"  and  in  the  other  the  vessels  of  the  diploe  "bleeding 
freely,"  probably  account  for  the  result.  These  were  both  cases  of 
secondary  trephining,  yet  I  mention  them  here  with  reference  to  the 
point  hinted  at  in  the  text. 


178  SURGERY    OF    THE    CRIMEAN    WAR. 

If  the  bone  be  very  deeply  depressed  on  the  brain,  and 
the  patient  be  comatose,  with  stertorous  breathing,  slow 
pulse,  and  dilated  pupil,  then  it  may  be  admissible  practice 
to  use  the  elevator  cautiously,  with  or  without  the  assistance 
of  Heys's  saw  ;  but  in  all  cases  in  which  the  bone  is  not  very 
deeply  depressed,  and  in  which  these  vsyrnptorns  are  not  very 
decidedly  marked,  nor  have  continued  for  a  considerable 
time,  I  do  not  believe  any  interference  should  be  attempted. 

It  is  too  much  the  custom,  I  think,  to  deny  or  overlook 
the  danger  which  arises  from  the  operation  itself.  This  is 
no  place  to  inquire  what  is  the  source  of  this  danger,  whether 
it  be  the  admission  of  atmospheric  air  to  the  membranes,  as 
supposed  by  Larrey  and  Stromeyer,  or  the  renewed  irrita- 
tion and  injury  of  the  brain  coverings,  or,  as  others  say,  from 
pus  poisoning ;  but  the  fact  recurs  that  the  most  serious, 
and  at  times  fatal,  symptoms  have  followed  the  operation 
itself  in  cases  in  which,  contrary  to  expectation,  the  parts 
below  the  bone  were  found  sound.* 

*  The  mortality  which  attends  the  operation  of  trephining  needs 
little  proof,  as  it  is  one  of  the  best  recognized  surgical  facts.  Take 
such  a  statement  as  that  of  Stromeyer,  who  tells  us  that  during  the 
three  years  he  attended  the  hospitals  of  Vienna,  London,  and  Paris, 
he  had  not  met  with  a  single  successful  case,  while  many  severe  in- 
juries recovered  which  were  left  alone.  In  the  New  York  hospital 
only  one-fourth  of  their  cases  recovered,  i.e.  eleven  cases  out  of 
forty-five.  In  ten  of  these  the  operation  was  prophylactic,  and  in 
thirty-two  therapeutic;  three  of  the  former  and  eight  of  the  latter 
recovered.  In  India  I  find  a  record  of  four  cases  of  trephining  for 
symptoms  setting  in  late,  and  all  ended  fatally.  In  the  Glasgow 
Hospital  register  I  find  no  record  of  a  recovery  after  trephining.  In 
University  College  Hospital  Mr.  Erichsen  speaks  of  four  cases  of  re- 
covery in  tl  ii'teen  operated  on,  and  in  the  Paris  hospitals  Nelaton 
telis  that  in  tilteen  years  all  their  operations  of  this  kind  for  trau- 
matic effusion  have  ended  fataily.  Mr.  Guthrie  thinks  the  danger 
greater  when  the  operation  is  performed  late.  He  thinks  the  sooner 
it  is  undertaken,  if  it  is  to  be  had  recourse  to  at  all,  the  better,  '-be- 
lieving the  violence  to  be  greater  when  done  on  parts  already  in  a 
state  of  inflammation,  than  when  they  are  sound."  Larrey  expresses 


INJURIES    OF   THE    HEAD.  179 

Injury  of  the  skull,  followed  at  a  late  date  by  compression, 
is  perhaps  the  most  hopeless  of  all  the  circumstances  in 
which  the  trephine  can  be  used,  yet  it  seems  that  in  which 
it  is  most  properly  and  incontestably  employed.  Rigors 
followed  by  vomiting,  a  rapid  pulse,  stupor,  delirium,  and 
palsy,  usher  in  a  condition  of  things  which,  except  in  rare 
cases,  is  fatal.  The  longer  the  time  which  intervenes  before 
the  appearance  of  such  symptoms,  the  more  deadly  does 
their  indication  appear  to  be.*  It  is  well  known  that,  in 
the  majority  of  these  cases,  the  pus  is  so  situated  that  it  can- 
not be  evacuated  by  the  trephine.  It  is  either  diffused  over 
the  brain  between  its  membranes,  or  collected  in  depots 
deep  within  its  substance,  or  at  parts  distant  from  the  seat 
of  injury.  In  a  considerable  number  of  cases,  however,  it 
lies  superficially,  when  its  formation  has  been  occasioned  by 
a  concentrated  blow  like  that  of  a  ball,  and  may  be  found 
collected  beneath  the  place  of  injury.  It  is  only  in  these 
latter  instances  that  any  good  can  be  got  from  the  use  of 

himself  in  almost  the  same  words:  "  We  say,  then,  that  the  trepan 
should  be  applied  when  ii  is  decidedly  indicated,  before  the  invasion 
of  inflammatory  symptoms,  which  show  themselves  more  or  less 
promptly,  according  to  the  idiosyncrasy  of  the  patient,  his  age,  and 
the  cause  of  the  wound  ;  and  when  it  is  developed,  the  operation 
should  be  delayed  till  these  symptoms  cease.  If  this  second  period 
does  not  present  ilself,  it  is  better  to  abandon  the  patient,  devoted  to 
certain  death,  than  to  try  a  useless  remedy  which  can  only  hasten 
his  last  moments." 

*  The  late  period  at  which  dangerous  symptoms  may  be  set  up,  the 
total  absence  of  any  irritation  caused  by  foreign  bodies  impacted  in 
the  brain,  which  is  occasionally  observed,  are  well  shown  in  a  case 
related  by  M.  Man  mry  in  his  report  on  Roux's  service  during  the 
year  1841.  A  student,  with  suicidal  intent,  shot  himself  by  the 
mouth.  The  ball  tore  the  jaw,  but  there  were  no  l;ead  symptoms.  On 
the  sixteenth  day  he  was  so  well  as  to  ask  for  his  discharge  from, 
hospital,  while  on  the  eighteenth  head  symptoms  set  in,  and  rapid 
death  ensued  The  wad  and  the  ball  were  found  in  the  brain,  and 
yet.  for  a  fortnight  not  the  least  sign  appeared  of  irritation,  or  of  the 
presence  of  such  formidable  bodies. 


180  SURGERY    OF    THE   CRIMEAN   WAR. 

the  trephine ;  but  such  cases  are  sufficiently  numerous  in 
their  occurrence  to  indicate  its  employment  in  all  instances 
in  which  distinct  signs  of  purulent  collection  set  in  at  a  late 
date.  "  It  is  plainly  an  abscess  of  the  brain,"  says  John 
Bell ;  "  and  as  it  is  an  abscess  which  cannot  burst  or  relieve 
itself,  though  the  trepan  may  fail  to  relieve  the  patient,  yet 
without  that  help  he  will  infallibly  die."  In  this  is  expressed 
the  true  reason  for  its  use  in  these  most  hopeless  cases.  It 
is,  in  fact,  a  last  resource,  which  we  are  not  justified  in  re- 
fusing to  avail  ourselves  of. 

Besides  this,  it  is  also  true  that,  in  a  considerable  number 
of  cases  in  which  the  pus  has  not  been  found  immediately 
beneath  the  seat  of  injury,  it  has  been  discovered  post-mor- 
tem, but  slightly  removed  from  it,  within  the  brain  substance 
— so  near  that  very  little  would  have  effected  its  evacuation  ; 
and  it  is  also  well  known  that  success  has  followed  the  bold 
expedient,  first  practiced  by  Dupuytren,  of  plunging  a  knife 
into  the  brain  when  the  abscess  was  not  found  on  its  surface. 
The  case  will  end  fatally  to  a  certainty,  if  the  matter  is  not 
evacuated  ;  and  in  the  event  of  the  attempt  failing,  such  a 
step,  if  conducted  with  proper  circumspection,  will  not  add 
to  the  gravity  of  the  case.  The  following  case  is  mentioned, 
not  only  because  of  the  late  appearance  of  urgent  symp- 
toms, but  also  because  of  the  position  of  the  abscess  found 
after  death,  which  was  situated  as  above  referred  to  :  A  pri- 
vate in  the  29th  was  hit  by  a  ball  above  the  eye.  The  fron- 
tal bone  was  smashed,  and  the  ball  was  lost  apparently  in 
the  brain.  No  head  symptoms  whatever  followed.  Some 
loose  pieces  of  bone  were  removed,  but  two  parts  which  were 
depressed  were  not  interfered  with.  The  antiphlogistic  treat- 
ment was  decidedly  maintained.  For  three  weeks  no  symp- 
toms appeared  to  create  alarm ;  at  the  end  of  that  period, 
however,  a  good  deal  of  local  inflammation  was  set  up,  and 
the  depressed  portions  of  bone,  being  found  loose,  were  re- 
moved. Very  little  disturbance  followed  this  step,  and  he 
was  finally  discharged,  about  four  months  after  the  receipt 


INJURIES   OP   THE   HEAD.  181 

of  the  injury,  apparently  quite  well.  A  month  after  dis- 
missal he  returned  into  hospital,  complaining  of  feverishness, 
headache,  and  a  hurried  and  excited  manner.  There  was 
nothing  particular  found  at  the  seat  of  injury.  The  cicatrix 
was  in  the  same  condition  as  when  he  left  the  hospital. 
The  brain-pulse  was  evident,  as  it  had  been  since  the  bone 
was  withdrawn.  Coma  occurred  shortly  after  his  admission, 
ending  in  death  sixty  hours  from  the  first  bad  symptom. 
When  the  head  was  opened,  the  hiatus  in  the  bone  remained 
unchanged,  only  that  the  edges  of  the  aperture  were  smoothed 
and  beveled  off,  and  somewhat  darker  in  color  than  the  rest 
of  the  calvarium.  The  dura  mater  was  thickened,  but  en- 
tire, and  adherent  at  the  place  of  wound.  The  other  brain- 
coverings  were  highly  inflamed,  and  sero-purulent  effusion 
existed  between  them.  A  small  abscess  was  found  in  the 
substance  of  the  brain,  immediately  below  the  place  of  inju- 
ry;  and  behind  this,  but  separated  from  it  by  a  thin  partition 
of  cerebral  substance,  was  a  larger  abscess  in  the  anterior 
lobe  of  the  brain,  which  communicated  with  the  lateral  ven- 
tricle of  the  left  side.  The  small  abscess  had  a  distinct  sac, 
but  the  larger  one  had  not.  Dr.  Taylor,  who  reports  the 
case,  adds :  "  These  collections  of  pus  might  have  been  of 
some  standing,  yet  the  patient  had  not  a  bad  symptom  up 
to  sixty  hours  before  death."  It  is  very  possible  that  dissi- 
pation after  dismissal  occasioned  the  sad  and  fatal  result. 

A  soldier  of  the  Royal  Artillery  was  admitted  into  the 
general  hospital,  on  the  15th  of  November,  on  account  of  a 
shell  wound  dividing  the  scalp  over  the  inner  and  anterior 
angle  of  the  left  parietal  bone.  He  walked  to  the  hospital, 
assisting  a  comrade  who  was  more  severely  hurt  than  him- 
self; and  he  complained  so  little  that  it  was  with  difficulty 
he  could  be  persuaded  to  go  to  bed.  A  piece  of  bone  about 
the  size  of  a  shilling  was  found,  on  examining  his  head,  de- 
pressed to  the  extent  of  about  an  eighth  of  an  inch  at  the 
scat  of  injury.  lie  was  purged,  put  on  low  diet,  and  his 
wound  dressed  simply.  In  live  days  he  was  allowed  to  rise 

16 


182  SURGERY    OF    THE   CRIMEAN    WAR. 

and  assist  in  the  business  of  the  ward — being  put  inadvert- 
ently, by  the  surgeon  under  whose  care  he  was,  on  full  diet 
and  a  gill  of  rum.  No  bad  symptoms  showed  themselves 
for  ten  days.  His  bowels  were  permitted  to  get  costive. 
His  wound  was  nearly  closed.  On  the  morning  of  the  fif- 
teenth day  from  admission  he  complained  of  giddiness  ;  his 
pulse  was  rapid,  and  his  face  flushed.  Leeches  and  cold 
were  ordered  to  the  head,  and  a  purgative  administered. 
He  rapidly  grew  worse.  The  wound,  now  dry  and  unhealthy, 
gave  out  but  a  slight  gleety  discharge.  He  made  many  at- 
tempts to  vomit,  which  was  encouraged  by  an  eme'tic.  His 
pupils  became  widely  dilated,  but  remained  sensible  to  the 
action  of  light.  A  fortnight  after  the  setting  in  of  these 
symptoms  he  was  found  to  be  hemiplegic  on  the  left  side. 
I  saw  him  at  this  period  for  the  first  time.  His  respiration 
was  sighing,  and  numbered  twenty-two  in  the  minute.  His 
pulse  was  ninety,  and  contracted.  His  mouth  and  tongue 
were  drawn  to  the  right  side.  He  was  sensible  when  roused, 
but  lay  in  a  half  state  of  sopor  when  not  addressed.  The 
next  day  the  trephine  was  applied  to  the  seat  of  injury,  and 
the  depressed  bone  removed  or  elevated.  The  dura  mater 
was  covered  by  a  pulpy  mass  of  lymph.  No  pus  was  found. 
Some  spiculae  of  the  inner  table  which  lay  on  the  dura  mater 
were  withdrawn.  His  symptoms  in  no  way  improved.  His 
tongue  was  next  day  drawn  to  the  left  side,  but  his  mouth 
was  unaffected.  He  had  several  severe  convulsions  over 
both  sides  of  his  body,  and  he  died  two  days  after  being 
trephined.  The  skull  was  found  fractured  across  the  sagit- 
tal suture  into  both  parietal  bones.  The  dura  mater  was 
little  detached  round  the  seat  of  injury ;  but  it  was  there 
dark  and  pulpy,  having  a  semi-organized  clot  on  its  surface. 
The  brain  was  softened  at  the  place  of  injury,  and  had  a  clot 
as  large  as  a  walnut  lying  on  it;  while  at  two  points  on  the 
opposite  hemisphere,  at  the  edge  of  the  longitudinal  fissure, 
soft  spots  were  found  about  -as  large  as  a  sixpence.  Pus 
existed  abundantly  below  the  membranes,  and  bathed  the 


INJURIES   OF   THE   HEAD.  183 

surface  of  the  right  hemisphere,  as  well  as  extended  to  the 
base  of  the  brain,  between  the  hemispheres  and  under  the 
cerebellum. 

The  neglect  as  to  diet  and  the  maintenance  of  the  secre- 
tions were  probably  the  cause  of  death  in  the  above  case. 
It  is  certainly  not  always  easy  to  maintain  as  careful  a  super- 
vision on  these  points  as  is  necessary,  when  no  functional 
disturbance  whatever  is  present,  and  the  injury  seemingly 
slight;  but  this  is  only  one  of  many  examples  which  might 
be  adduced  to  show  the  necessity  of  the  long  and  careful 
watching  which  such  cases  require. 

The  above  was  one  of  the  only  two  instances  in  which  the 
trephine  was  employed  in  the  general  hospital,  and  both 
ended  fatally.  In  the  other  case,  it  was  used  by  one  of  my 
colleagues  for  signs  of  compression  setting  in  early,  with 
bone  much  and  extensively  depressed. 

Finally,  judging  of  this  question  from  an  examination  of 
the  writings  of  our  great  masters,  the  conclusion  which  pre- 
sents itself  is,  that  as  the  symptoms  calling  for  the  use  of  the 
trephine  have  been  so  variously  interpreted  by  men  of  ex- 
perience ;  that  as  the  operation  has  failed  as  often  as  it  has 
succeeded  in  removing  the  dangers  apprehended ;  that  as 
the  good  which  has  occasionally  followed  is  ascribable,  in 
many  cases,  to  other  concurrent  circumstances,  and  not  to 
the  removal  of  the  bone ;  and  finally,  that  as  the  operation, 
per  se,  is  not  devoid  of  danger, — we  should  never  have  re- 
course to  the  trephine,  unless  the  indications  for  its  use  are 
very  decided,  have  been  present  for  some  considerable  time, 
and  have  not  been  assuaged  by  other  remedial  measures. 

Further,  I  am  disposed,  not  only  from  reading,  but  also 
from  the  observation  of  not  a  few  cases  which  fell  under  my 
notice  during  the  late  war,  to  conclude,  regarding  the  cases 
and  symptoms  which  demand  operation — that,  primarily, 
operative  interference  (under  which  term  is  included  the  use 
of  the  trephine,  saw,  or  elevator)  in  gunshot  wounds  of  the 
head  should  never  be  had  recourse  to,  except  (1)  in  cases  of 


184  SURGERY    OF   THE    CRIMEAN    WAR. 

fracture  with  great  depression — cases  in  which  the  bone  is 
forced  deeply  into  the  brain,  especially  if  it  is  turned  so  that 
a  point  or  an  edge  is  driven  into  the  cerebral  mass ;  or  (2) 
unless  we  clearly  make  out  the  impaction  of  spiculse,  balls,  or 
other  foreign  bodies  in  the  brain,  which  cannot  be  removed 
through  the  wound  by  means  of  the  forceps :  that,  second- 
arily, the  cases  which  call  for  operation  are  (1)  those  in 
which  a  foreign  body  is  at  this  period  discovered  irritating 
the  brain,  and  which  cannot  be  extracted  without  a  piece  of 
the  bone  being  removed;  or  (2)  those  in  which  signs  of 
compression,  set  in  after  a  well-marked  rigor,  continue  to 
increase  in  intensity,  notwithstanding  treatment,  and  have 
lasted  for  some  time. 

In  the  treatment  of  gunshot  injuries  of  the  head,  opera- 
tive proceedings  form  the  least  important  items,  as  they  can 
commonly  be  avoided  if  the  rest  of  the  management  be  ju- 
dicious, and  their  success  will  chiefly  depend  on  a  careful 
attention  to  less  imposing  but  more  important  measures. 

In  their  examination  the  finger  should  alone  be  employed, 
and  that  even  with  much  caution.  They  should  not  be  en- 
larged, unless  a  more  important  object  be  held  in  view  than 
to  clear  up  doubtful  points  of  diagnosis.  If  the  bone  be  so 
extensively  destroyed  and  depressed  as  to  demand  early  in- 
terference, it  will  make  itself  sufficiently  evident  without  its 
being  necessary  to  incise  the  scalp  for  the  purpose  of  making 
the  distinction.  Stromeyer  fitly  recommends  the  application 
of  a  piece  of  wet  linen  to  the  wound,  which,  as  it  adheres  to 
the  scalp,  excludes  the  air.  Cold — ice,  if  possible,  or  if  it 
cannot  be  had,  simple  water — should  be  applied  over  this  ; 
the  patient  put  to  bed  in  a  tent  by  himself;  an  active  purga- 
tive administered,  and  a  most  meager  diet  allowed.  The 
utmost  quiet  should  be  enforced,  and,  in  short,  the  antiphlo- 
gistic treatment  very  decidedly  and  completely  carried  out. 
He  should  be  visited  frequently ;  and  if  any  signs  of  inflam- 
matory or  excited^  action  supervene,  instant  and  copious 
bleeding  should  be  put  in  force.  "  Of  all  the  remedies  in 


INJURIES   OP   THE    HEAD.  185 

the  power  of  art,"  says  Pott,  "for  inflammations  of  mem- 
branous parts,  there  is  none  equal  to  phlebotomy,  and  if 
anything  can  particularly  contribute  to  the  prevention  of  the 
ills  likely  to  follow  severe  contusions  of  the  head,  it  is  this 
kind  of  evacuation  ;  but  then  it  must  be  made  use  of  in  such 
a  manner  as  to  become  truly  a  preventive,  that  is,  it  must 
be  made  use  of  immediately  and  freely."  I  never  saw  any 
good  arise  from  the  use  of  tartar  emetic  in  these  cases. 
Cold  locally,  purgatives,  low  diet,  and  early  bleeding,  re- 
peated freely  when  signs  of  disturbance  showed  themselves  ; 
these,  with  the  application  of  leeches  in  some  cases  to  the 
head,  seemed  always  sufficient,  as  they  are  the  most  useful 
means  of  treating  such  patients. 

As  to  the  extraction  of  balls  when  lodged  in  the  brain, 
the  rule,  I  believe  almost  universally  followed  in  the  army, 
is  to  extract  them  if  they  can  be  at  all  got  at.  It  is  true 
that  masses  of  a  far  more  formidable  nature  than  balls  have 
remained  on  and  even  in  the  brain  without  mischief,  and 
that  balls  have  been  discovered  encysted  years  after  their 
entrance.  But  these  cases  form  a  mere  fraction  of  the  num- 
ber in  which  the  presence  of  the  ball  has  determined  fatal 
complications;  yet  they  are  the  ignes  fatui  by  which  some 
would  mislead  us  from  the  plain  path  of  duty,  which  incul- 
cates the  removal  of  such  foreign  bodies,  if  at  all  practicable. 
Sir  B.  Brodie,  arguing  from  an  analysis  of  the  published 
cases,  advocates  their  abandonment  unless  superficially 
placed  ;  but  from  this  view  nearly  all  military  surgeons  dis- 
sent. In  our  proceedings,  however,  "boldness  must  not 
partake  of  temerity."  Few  would  have  the  courage  or  con- 
fidence of  Larrey  or  Sir  Charles  Bell,  to  follow  and  extract 
the  ball  from  the  side  of  the  head  opposite  to  the  place  of 
entrance,  or,  like  Scdillot,  pursue  it  to  the  depth  of  several 
inches  in  the  cerebral  substance;  yet  all  reasonable  attempts 
ought  to  be  made  for  its  extraction.  "  Nothing,"  says  Sir 
George  Ballingall,  "  will  induce  me  to  countenance  the  prac- 
tice of  leaving  it  there,  except  the  impossibility  of  finding 

16* 


186  SURGERY    OF   THE    CRIMEAN    WAR. 

it;"  and  again,  "I  am  of  opinion  that  it  ought  to  be  ex- 
tracted even  at  the  risk  of  some  additional  injury ;  in  short, 
the  prohibition  of  violence  ought  rather  to  apply  to  the 
search  after  balls  than  to  the  operation  of  extracting  them." 
"  We  have  already  cited  several  cases,"  says  Quesney,  "  which 
teach  us  that  foreign  bodies  may  remain  a  long  time  in  the 
brain  without  causing  death  ;  but  with  this  knowledge  we 
must  also  bear  in  mind  that  it  is  our  duty  to  extract  these 
bodies,  which,  sooner  or  later,  almost  always  prove  fatal  to 
the  patients ;  and  when  we  have  reason  to  suspect,  from  the 
events,  from  the  instrument  which  inflicted  the  wound,  or  from 
the  state  of  the  fracture  of  the  skull,  that  such  bodies  are 
retained  and  concealed  in  the  substance  of  the  brain,  we 
should  make  the  necessary  examinations  for  the  discovery." 

If  the  ball  has  penetrated  deeply  into  the  brain,  it  is  a 
matter  of  little  moment  what  steps  are  taken.  Perhaps  the 
best  line  of  conduct  is  to  let  the  man  die  in  peace.  I  have 
never  known  a  case  of  perforating  gunshot  wound  of  the 
head  recover.  Some  such  are,  however,  on  record. 

Cases  in  which  pieces  of  loose  bone  remain  on  the  dura 
mater  do  not  always  require  to  be  interfered  with.  Many 
surgeons  of  large  experience  in  the  Crimea  preferred  leaving 
them  to  be  thrown  out  by  the  natural  effort,  and  were  not 
particular  even  about  keeping  the  wound  open.  However, 
I  believe  this  practice  to  be  often  dangerous,  and  that  loose 
portions  of  bone  should  always  be  cautiously  removed.  The 
evil  effects  of  leaving  them,  as  well  as  the  injurious  influence 
of  too  early  a  recurrence  to  a  stimulant  diet,  were  well 
marked  in  the  following  case  :  M'Louchlin,  a  private  in  the 
Connaught  Rangers,  aged  19,  was  admitted  into  the  general 
hospital  on  the  8th  September.  He  had  been  knocked 
down  and  rendered  insensible  by  a  blow  from  a  piece  of 
shell  in  the  final  assault  on  the  Redan.  A  scalp  wound,  two 
and  a  half  inches  long,  was  found  extending  from  before 
backward  over  the  vertex  of  the  head,  and  a  small  piece  of 
bone  was  observed  to  be  depressed  at  its  anterior  extremity. 


INJURIES   OF   THE   HEAD.  1ST 

The  patient  did  not  become  conscious  for  twenty-four  hours 
after  admission.  Purging  and  low  diet  comprised  his  treat- 
ment. Cold  dressing,  and  nothing  else,  was  applied  to  the 
wound.  He  remained  perfectly  well,  complaining  only  of 
slight  headache  and  giddiness,  for  three  months,  small 
pieces  of  bone  being  discharged  in  the  mean  time  from  the 
wound,  which  had  almost  closed.  After  being  about  a 
month  in  hospital,  he  was  allowed  full  diet,  and  a  gill  of 
grog  daily.  On  the  8th  of  December,  three  months  after 
receiving  his  wound,  he  complained  of  a  sort  of  transient 
paralysis  of  the  left  arm,  which,  although  it  continued  only 
for  a  second  or  two  at  a  time,  recurred  frequently.  His 
sense  of  smell,  too,  suddenly  left  him.  There  was  no  other 
symptom.  On  being  questioned,  he  said  he  had  had  a  rigor 
and  several  "fainting  fits"  during  the  days  immediately 
preceding  that  on  which  he  first  complained  of  the  paralysis. 
Next  day  he  had  a  more  prolonged  fit  of  paralysis  during 
the  night  than  he  ever  had  had  before,  the  attack  being 
preceded  by  pain  in  the  left  side.  I  first  saw  him  during  an 
attack  on  the  9th  of  December,  which  was  more  severe  and 
more  prolonged  than  any  preceding  one.  His  left  arm 
hung  powerless,  and  there  was  complete  anesthesia  of  the 
left  arm  and  side  from  the  clavicle  to  the  false  ribs,  and 
from  the  line  of  the  nipple  to  the  spine.  The  left  side  of 
the  neck  behind  the  sterno-mastoid  was  also  without  sensa- 
tion. His  face  was  unaffected.  The  integuments  around 
the  wound  were  puffy,  and  very  sensitive.  He  said  that 
his  uneasy  feelings  had  gradually  increased  as  the  wound 
closed.  His  bowels  were  opened  freely,  and  a  light  poultice 
was  applied  to  the  wound,  which  was  incised.  The  fit  he 
had  on  the  9th  passed  off,  leaving  the  arm  weak.  The  sen- 
sibility of  the  left  side  slowly  returned  during  the  succeeding 
days.  The  fits  of  paralysis  came  and  went,  his  arm  recover- 
ing its  power,  in  a  great  measure,  between  them.  A  sharp 
bit  of  bone  was  at  last  observed  lying  on  the  dura  mater, 
and  when  it  was  removed,  the  untoward  symptoms  disap- 


188  SURGERY    OF   THE    CRIMEAN    WAR. 

peared.  Shortly  after  this  he  came  under  my  care.  By 
quiet  and  the  use  of  unstimulating  food  and  laxatives  he 
progressed  most  favorably ;  but  on  several  occasions  tran- 
sient feelings  of  weakness — for  there  never  again  was  a  state 
of  paralysis  established — passed  over  the  left  side,  when  any 
scale  of  bone  became  loose  and  lay  on  the  dura  mater,  and 
so  soon  as  this  was  removed  these  feelings  left.  If  his 
bowels  became  costive,  even  for  a  very  short  time,  not  only 
did  the  headache  and  giddiness  increase,  but  the  numbness 
in  the  side  returned.  When  he  left  for  England  no  bits  of 
bone  could  be  discovered,  and  the  wound  was  nearly  closed ; 
and  he  is  now,  I  understand,  doing  duty  with  his  regiment. 
Many  of  the  symptoms  in  this  case  were  those  set  down  as 
calling  for  the  use  of  the  trephine;  but  the  cautious  removal 
of  the  fragments  when  loose,  the  local  bleeding,  and  the 
purging,  did  all  that  was  required. 

Stromeyer  warns  us  particularly  against  attempting  too 
soon  to  remove  pieces  of  necrosed  bone,  as  he  thinks  they 
do  little  harm  if  allowed  to  remain.  In  this  my  own  ob- 
servation leads  me  by  no  means  to  agree.  If  the  dead  piece 
can  be  removed  without  violence,  I  believe  it  should  always 
be  done  as  soon  as  it  is  found  to  be  loose. 

On  the  treatment  of  hernia  cerebri  I  have  no  remarks  to 
offer. 

Hardly  less  important  than  the  immediate  treatment  of 
gunshot  wounds  of  the  head,  is  their  after-management. 
No  class  of  cases  requires  more  lengthened  and  careful 
supervision.  Relapses  may  occur  long  after  the  patient  is 
apparently  beyond  danger;  and  from  the  most  insignificant 
causes — of  which,  perhaps,  irregularities  in  food,  the  use  of 
alcoholic  stimuli,  and  retained  evacuations,  occupy  the  fore- 
ground— a  chronic  inflammatory  condition  of  the  membranes 
is  apt  to  become  established,  which  is  no  less  difficult  to 
manage  than  dangerous  in  its  ultimate  results.  Yery 
many  cases  are  on  record  in  which  men  with  balls  imbedded 
in  the  brain  have  apparently  recovered  completely,  but 


INJURIES  or  THE  HEAD.  189 

have  suddenly  fallen  down  dead  when  they  had  got  drunk 
or  excited. 

The  following  cases  are  added,  as  in  some  measure  illus- 
trating injuries  of  various  parts  of  the  head.  They  are 
selected  from  a  large  number  whose  features  are  nearly 
parallel : — 

Hughes,  an  artilleryman,  was  admitted  into  the  general 
hospital  under  my  colleague,  Mr.  Rooke,  on  the  15th  of 
November.  lie  had  been  struck  over  the  upper  part  of  the 
occipital  bone  by  a  piece  of  shell,  when  the  siege-train  oil 
the  right  attack  exploded.  He  was  rendered  insensible  by 
the  blow.  The  scalp  was  considerably  lacerated  over  the 
right  upper  part  of  the  occiput,  where  a  stellate  fracture  was 
found,  part  of  the  bone  being  depressed  for  about  a  quarter 
of  an  inch  below  the  surface.  He  recovered  some  degree  of 
consciousness  a  short  time  after  receiving  the  blow,  but  was 
dull  and  stupid  when  admitted  into  hospital,  answering 
questions  if  urgently  put  to  him.  His  head  was  shaved, 
and  cold  applied.  The  next  day  he  was  rational ;  his  eyes 
were  bloodshot,  but  beyond  this  there  was.no  bad  symptom. 
Purging,  and  cold  locally  applied,  were  used.  A  few  days 
afterward  he  had  headache  and  intolerance  of  light.  Dim- 
ness of  vision  and  flushing  of  the  face  followed,  but  there 
was  no  notable  peculiarity  in  the  pulse  or  pupil.  Leeches 
were  now  applied  to  the  mastoid  processes ;  beyond  this, 
the  use  of  laxatives  and  low  diet,  nothing  else  was  required 
to  dissipate  all  threatening  symptoms,  and  he  left  for 
England,  in  January,  quite  recovered. 

In  the  above  case  we  had  merely  concussion  at  first,  fol- 
lowed by  a  threatening  of  traumatic  encephalitis.  The 
treatment  was  simple,  and  the  cure  complete. 

Clarke,  private,  38th  Regiment,  aged  twenty-two,  was 
wounded  on  the  morning  of  the  18th  of  June,  but  was  not 
brought  into  hospital  till  the  evening  of  the  19th,  as  he 
lay  where  he  could  not  be  got  at  till  the  armistice.  A  piece 
of  shell  had  struck  him  on  the  upper  part  of  the  occiput, 


190  SURQERY   OF    THE   CRIMEAN    WAR. 

laying  the  scalp  open  to  an  extent  of  two  inches  and  a  half. 
The  bone,  though  denuded,  was  not  seen  to  be  fractured. 
His  symptoms  were  dizziness,  pain  in  the  forehead,  and 
great  throbbing  in  the  temples.  He  was  quite  rational,  but 
dull,  and  had  double  vision  and  strabismus.  His  pupils 
were  slightly  contracted.  His  chief  complaint  then,  and  for 
some  days  after,  was  of  his  neck  and  lower  jaw,  which  had 
received  no  injury ;  but  the  parotid  and  submaxillary  glands 
were  swollen  on  the  wounded  side — a  symptom  which  I  have 
observed  in  several  similar  cases.  His  pulse  was  forty  per 
minute  when  lying  down,  and  sixty-nine  when  he  sat  up. 
By  active  purging,  and  cupping  the  nape  of  the  neck,  and 
by  the  use  of  low  diet,  his  bad  symptoms  gradually  dis- 
appeared. For  some  days  after  admission  his  pulse  did  not 
change,  except  that  on  one  occasion  it  fell  to  thirty-eight 
beats  per  minute ;  but  as  he  got  better,  it  rose  to  the 
healthy  standard.  On  three  different  occasions,  while  he 
was  under  my  charge,  his  bowels  being  unrelieved  for  a  day, 
his  bad  symptoms  returned  in  a  modified  degree,  and  his 
pulse  sank ;  while  whenever  his  bowels  were  freely  opened, 
all  uneasiness  vanished,  and  his  pulse  again  rose.  The 
alternation  was  most  curious,  and  very  rapidly  developed. 
This  case,  like  many  others,  illustrated  well  the  marked 
sympathy  which  exists  between  the  head  and  the  bowels. 
The  same  slowness  of  the  pulse  was  noticed  by  Dr.  John 
Thomson,  in  the  case  of  a  similar  injury  after  Waterloo. 

A  French  soldier  received  a  ball  about  an  inch  behind 
the  left  ear,  which  escaped  above  the  eye  of  the  same  side. 
His  antagonist,  who  shot  him,  was  close  to  him  at  the 
moment  he  fired.  This  man  fell  down  insensible,  and  was 
carried  to  the  ambulance ;  but  he  recovered  his  senses 
before  his  arrival  there.  There  was  a  little  blood  oozing 
from  both  openings ;  he  was  dull,  but  sensible,  and  com- 
plained much  of  a  throbbing  pain  throughout  his  head. 
The  ball  having  escaped,  nothing  was  done  for  him,  further 
than  picking  away  some  small  loose  fragments  of  bone,  and 


INJURIES   OP   THE    HEAD.  191 

applying  wet  dressing.  He  was  freely  purged,  and  got  no 
food.  In  twenty-four  hours,  the  puin  in  the  head  having 
greatly  increased,  and  being  accompanied  by  delirium,  with 
rapid  pulse,  ferrety  eyes,  and  hot  skin,  he  was  largely  bled, 
and  cold  was  applied  to  his  head.  His  symptoms  were 
relieved,  and  from  that  day  he  never  had  a  bad  symptom, 
all  the  treatment  his  case  required  being  merely  low  diet 
and  free  purging. 

Another  almost  identical  case  occurred  in  our  own  hospital 
at  Scutari,  where  I  saw  the  patient  under  the  charge  of 
Staff-Surgeon  Menzies.  The  ball  had  in  this  case  entered 
two  inches  behind  the  left  ear,  passed  deeply,  and  was 
removed  from  the  temple.  Some  hemorrhage  set  in  from 
both  wounds,  as  well  as  from  the  ear,  a  few  days  after 
injury,  but  it  was  arrested  by  pressure.  He  was  dull,  and 
complained  of  headache  for  a  few  days  after  the  occurrence 
of  the  bleeding ;  but  by  low  diet  and  purging  he  made  an 
excellent  recovery,  only  that  his  hearing  was  destroyed  on 
the  wounded  side. 

A  soldier,  aged  nineteen,  belonging  to  the  Second  Divi- 
sion, was  struck  at  Inkerman  by  a  rifle-ball,  over  the  ver- 
tex of  the  head  to  the  right  of  the  center  line.  The  ball, 
passing  from  before  backward,  "furrowed"  the  bone,  break- 
ing both  tables.  This  patient  declared  that  he  never  lost 
his  senses,  but  felt  so  weak  that  he  had  to  sit  down.  He 
walked  to  the  hospital,  where  he  was  twice  bled  and  actively 
purged.  The  bone  along  the  line  of  the  ball's  passage,  being 
broken  into  small  fragments,  was  removed  with  the  forceps, 
and  cold  was  applied.  The  brain  was  bared,  but  the  dura 
mater,  although  scratched,  was  not  found  torn.  A  threat- 
ened attack  of  inflammation  of  the  brain  was  successfully 
combated  by  repeated  venesections  and  purging,  and  the 
patient  made  a  good  recovery — a  sulcus  about  two  inches 
long  being  felt  by  the  finger  over  the  vertex,  the  brain  pul- 
sations being  distinguishable  at  one  extremity  of  it. 

An  artilleryman  was  wounded  on  the  eighteenth  of  June 


192  SURGERY   OF    THE    CRIMEAN    WAR. 

by  a  piece  of  shell  over  the  back  part  of  the  head  and  ren- 
dered insensible.  He  soon  recovered,  rose,  and  walked  un- 
assisted to  the  general  hospital.  No  fracture  was  at  first 
detected,  and  the  lacerated  scalp  wound  which  existed  was 
dressed  simply  by  the  surgeon  under  whose  charge  he  fell. 
Headache  alone  was  complained  of  for  some  days,  during 
which  period  he  was  kept  low,  and  freely  purged.  When 
the  wound  was  nearly  healed,  he  was  unfortunately  allowed 
butcher  meat  and  a  gill  of  rum.  About  a  week  afterward, 
severe  cerebral  symptoms  rapidly  and  suddenly  showed  them- 
selves, and  the  wound  took  on  an  unhealthy  action.  The  injury 
was  now  more  carefully  examined,  the  scalp  being  incised  to 
assist  the  investigation.  A  fracture  of  the  occipital  bone 
was  found.  Bleeding  was  encouraged  from  the  incision ; 
leeches  were  placed  on  the  mastoid  processes ;  he  was  well 
purged,  and  cold  applied  to  the  head.  His  diet  was  again 
reduced.  The  unfavorable  symptoms  almost  immediately 
subsided,  and,  by  the  use  of  low  diet  and  purgatives,  soon 
totally  disappeared  never  to  return.  In  this  case  a  too  gener- 
ous diet  doubtless  caused  the  appearance  of  the  unpleasant 
symptoms  which  supervened,  and  which,  if  not  promptly 
arrested,  would  have  been  fatal.  The  local  bleeding  assisted 
materially;  but  the  active  purging,  the  cold  applications, 
and  the  low  diet  were  the  chief  means  of  saving  him. 

The  following  case,  the  particulars  of  which  were  kindly 
furnished  me  by  Acting  Assistant-Surgeon  Brock  of  the 
47th  Regiment,  was  a  most  interesting  one,  not  only  from 
the  extent  of  the  injury,  but  from  "  the  phases  of  recovery  :" 

Keefe,  a  private  in  the  47th  Regiment,  aged  23,  was 
struck,  on  the  15th  November,  by  a  piece  of  shell  over  the 
vertex  of  the  head,  and  felled  to  the  ground.  When  found, 
a  short  time  afterward,  he  was  apparently  dead.  The  sur- 
face of  his  body  was  cold,  his  pupils  widely  dilated  and  in- 
sensible to  light,  no  respiration  or  motion  of  the  blood  per- 
ceptible. His  face  was  much  scratched  and  congested. 
Some  blood  flowed  from  the  right  nostril,  and  the  superfi- 


INJURIES   OP    THE    HEAD.  193 

cial  veins  of  his  neck  were  gorged.  The  main  wound  in  the 
scalp  extended  nearly  from  ear  to  ear,  across  the  vertex  of 
the  head ;  and  lesser  wounds  passed  in  different  directions 
from  this  great  one.  The  flaps  of  the  scalp  formed  by  these 
wounds  were  reflected  in  different  directions.  A  large  por- 
tion of  the  bone  was  seen  to  be  destroyed,  and  the  space  left 
was  filled  by  coagulated  blood.  The  patient  was  seen  by 
several  surgeons,  and  so  impressed  were  they  that  life  was 
extinct  that  he  was  carried  to  the  tent  set  apart  for  the 
dead.  Twenty-five  minutes  afterward,  on  being  again 
visited,  some  faint  signs  of  life  were  observed.  There  was 
a  flutter  at  the  wrist,  and  an  occasional  sigh.  Profuse  bleed- 
ing from  the  head  followed,  and  on  the  clot,  which  was  seen 
to  be  mixed  with  cerebral  matter,  being  removed,  it  was 
found  that  the  bones  forming  the  vertex  of  the  head  were 
destroyed  to  the  extent  of  2£  to  2J  square  inches.  In  this 
was  included  part  of  the  superior  angle  of  the  occipital  bone 
and  a  part  of  both  parietal  bones,  the  sagittal  suture  being 
clearly  defined  along  the  center  of  one  detached  piece.  Part 
of  this  extent  of  bone  was  altogether  gone,  and  the  rest, 
being  detached,  was  removed. 

The  surface  of  the  dura  mater  was  scratched,  but  not 
torn,  except  at  one  spot — at  the  lateral  and  posterior  part 
of  the  wound — where  it  was  lacerated,  and  from  which  a 
spicula  of  bone  an  inch  long,  and  which  was  imbedded  in 
the  right  hemisphere  of  the  brain,  was  removed,  a  piece  of 
cerebral  matter  the  size  of  a  nut  adhering  to  it.  The  brain 
at  this  part  seemed  soft  and  broken  down.  Some  depressed 
bone  was  elevated,  and  all  loose  scales  removed.  The  scalp 
was  brought  together  by  suture,  and  lint  wetted  in  cold 
water  applied.  Next  day  the  patient  was  quite  unconscious, 
lay  on  his  back,  and  breathed  regularly  and  naturally.  His 
pulse  was  very  weak,  and  his  surface  warm  and  moist.  He 
passed  his  urine  in  bed.  His  pupils  were  dilated  and  insen- 
sible to  light.  He  could  swallow  freely.  During  the  two 
following  days  his  state  was  unaltered.  Both  eyes  became 

17 


194  SURGERY   OF   THE    CRIMEAN   WAR. 

affected  with  strabismus.  The  treatment  consisted  of  purg- 
ing, cold  to  the  head,  and  the  most  sparing  diet.  On  the 
fifth  day  there  were  some  signs  of  returning  consciousness. 
He  tried  to  change  his  posture,  and  crossed  his  arms  on  his 
breast.  His  pupils,  too,  acted  feebly,  and  a  profuse  per- 
spiration covered  the  surface  of  his  body.  On  the  follow- 
ing day  he  again  relapsed,  and  the  wound,  which  had  begun 
to  suppurate,  now  became  glazed  and  dry.  When  his  bowels 
were  got  to  act  freely,  he  again  improved  and  became  con- 
scious. He  complained  of  pain  in  the  head  and  down  the 
left  side  of  his  body.  Thus  he  went  on  till  the  eleventh 
day,  being  conscious  and  able  to  speak.  His  bowels  were 
carefully  kept  acting.  His  pupils  had  up  to  this  time  come 
to  contract  and  expand  freely,  and  the  wound  was  suppura- 
ting kindly.  He  slept  much,  and  expressed  a  great  desire 
for  food.  On  the  eleventh  day  he  became  suddenly  restless 
and  delirious,  particularly  at  night.  The  strabismus  re- 
turned. His  eye  became  dull  and  semi-glazed,  and  his  pupils 
were  widely  dilated  and  little  affected  by  light.  By  the 
eighteenth  day  these  untoward  symptoms  had  in  a  great 
measure  abated.  He  was  sensible,  and  craved  for  food. 
His  left  side  was  found  to  be  paralyzed,  the  face  not,  how- 
ever, being  implicated.  His  pupils  were  still  somewhat 
dilated,  but  active.  There  was  also  some  oedema  of  the  feet 
and  ankles.  By  the  twenty-third  day,  granulations  had 
formed  round  the  wound.  Part  of  the  scalp  had  adhered 
by  the  first  intention.  His  sleep  was  now  natural  and  un- 
disturbed. Except  the  temporary  irritation  caused  by  some 
spieulee  of  bone,  he  went  on  improving  from  that  time.  At- 
tention to  his  diet  and  the  state  of  his  bowels,  and  allowing 
a  free  exit  for  the  secreted  pus,  comprised  all  the  treatment 
followed  in  this  case.  If  his  bowels  were  for  a  day  unre- 
lieved, the  bad  symptoms  immediately  reappeared.  I  ex- 
amined him  previous  to  his  going  to  England,  in  January, 
and  at  that  period  he  was  in  every  way  recovered.  The 
head  wound  was  entirely  closed,  but  a  depression  to  the  ex- 


INJURIES   OF   THE   HEAD.  195 

tent  of  about  three-fourths  of  an  inch  existed  over  the  site 
of  the  injury,  and  the  pulsations  of  the  brain  were  quite 
perceptible. 

I  learn  from  Deputy-Inspector  Taylor  that  Keefe  was 
invalided  at  Fort  Pitt,  on  the  28th  May,  1856,  on  account 
of  "general  loss  of  sensibility  and  motion,  partial  in  the 
upper,  but  most  complete  in  the  lower  extremities."  He 
was  in  hospital  at  Chatham,  from  23d  March  to  26th  June, 
1856,  his  state  being  as  follows:  "The  wound  on  the  head 
formed  two  sides  of  a  triangle,  and  is  about  two  and  a  half 
inches  in  length  on  the  right  side,  and  much  longer  on  the 
left.  It  is  quite  healed,  but  there  is  a  very  considerable 
depression.  The  pulsations  of  the  brain  are  quite  percep- 
tible. Complains  of  severe  pain  across  the  forehead,  of  an 
intermittent  type.  Has  lost  the  power  of  his  lower  extremi- 
ties, with  the  exception  of  being  able  to  draw  them  up  and 
stretch  them  out  in  bed.  Has  not  lost  much  flesh,  and  his 
general  health  and  functions  good."  He  thus  appears  to 
have  relapsed  after  leaving  the  Crimea,  as  the  marked 
paralysis  he  had  at  Chatham  did  not  exist  when  he  left 
camp. 

The  intermittent  headaches,  spoken  of  in  this  case,  are 
among  the  most  troublesome  sequences  of  injuries  of  the 
head.  A  careful  regulation  of  the  bowels  and  diet,  with 
blisters  to  the  nape,  and  morphia,  appeared  to  me  the  best 
remedies.  It  is  a  remarkable  feature  in  the  progress  of  head 
cases,  how  often  the  setting  up  of  subacute  inflammation 
shows  itself  by  an  aggravation  of  the  leading  symptom — 
whatever  that  may  be  —  which  had  existed  before:  the 
headache,  palsy,  or  epileptiform  fits.  This  was  clearly 
defined  in  several  cases. 

The  following  is  an  example  of  a  severe  injury  of  the 
fore  part  of  the  head,  caused  by  a  piece  of  stone : — 

A  French  chasseur-a-pied  was  struck  on  the  center  of 
the  forehead,  above  the  root  of  the  nose,  by  a  piece  of  stone 
about  the  size  of  a  walnut,  knocked  up  by  a  shell.  The 


196          SURGERY  OF  THE  CRIMEAN  WAR. 

stone  completely  buried  itself,  and  required  some  skill  to 
extract  it.  Pieces  of  bone,  comprising  nearly  the  whole 
ethmoid,  were  discharged,  and  a  large  hole  in  the  frontal 
bone  resulted.  Three  clays  afterward  transient  but  easily- 
allayed  head  symptoms  appeared,  and  he  made  a  most 
excellent  recovery,  with  a  fistulous  opening,  however,  re- 
maining. The  interest  attaching  to  this  case  arose  from 
the  fact  that  the  inner  table  of  the  skull  was  not  fractured, 
and  from  the  almost  total  absence  of  any  head  symptoms. 

It  is  well  known  that  balls  may  perforate  the  outer  table 
of  the  skull  on  the  forehead,  without  injuring  the  inner.  Of 
this  the  above  may  be  taken  as  an  example,  although  a 
stone,  and  not  a  leaden  ball,  was  the  missile.  Several  cases 
occurred  in  the  Crimea  of  another  wound  on  the  forehead 
which  is  curious,  viz.,  such  as  are  caused  by  balls  passing 
from  side  to  side  of  the  head  below  the  level  of  the  brain, 
but  destroying  one  or  both  eyes. 

At  Inkerman  a  French  soldier  was  struck  by  a  ball  over 
the  upper  part  of  the  left  parietal  bone.  A  comminuted 
fracture  was  caused,  the  bone  to  the  extent  of  a  square 
inch  being  so  broken  and  detached  as  to  be  removed  at  the 
first  dressing.  The  dura  mater  was  slightly  injured,  and  a 
small  spiculurn,  which  had  been  driven  into  the  brain,  was 
withdrawn.  He  remained  speechless  for  about  a  week, 
then  articulated  hesitatingly,  and  finally,  about  six  weeks 
from  the  receipt  of  the  wound,  completely  recovered  his 
power  of  speech.  The  curious  thing  in  this  case  was,  that 
perfect  anesthesia  of  the  thumb  and  first  two  fingers  of  the 
right  hand  existed  from  the  moment  of  injury,  without  any 
loss  of  motion  whatever,  and  that  this  slowly  disappeared 
as  the  wound  healed,  and  he  recovered. 

To  multiply  cases  would  be  of  little  use.  The  teaching 
of  all  was  to  lead  us  to  wait ;  to  purge  the  patient  thor- 
oughly ;  to  remove  only  such  pieces  of  bone  as  could  be  got 
at  with  forceps,  and  which  were  quite  detached  and  loose ; 
to  bleed,  if  need  be,  locally  and  even  generally;  to  use 


INJURIES   OF   THE    HEAD.  197 

cold  applications  when  there  was  a  fear  of  inflammation  ;  to 
enjoin  perfect  rest  not  only  to  the  body  generally,  but,  if 
possible,  to  give  repose  to  the  special  senses  also,  by  isola- 
ting the  patient,  and  thus  removing  the  stimuli  to  their 
exercise ;  to  enforce  the  lowest  diet,  and  to  continue  all  this 
treatment  for  a  long  period,  even  after  all  danger  seemed 
past ;  and,  finally,  to  treat  any  incidental  complications  on 
general  principles. 

It  is  extremely  difficult  to  get  soldiers  to  avoid  stimuli, 
or  to  attend  to  their  secretions;  and  the  desire  for  improved 
diet  leads  them  sometimes  to  deceive  one  as  to  their  feelings. 
The  discipline  of  a  field  hospital  can  often  be  infringed,  and 
as  it  is  not  easy  to  persuade  men  of  the  soldier's  disposition, 
of  a  danger  of  which  their  sensations  give  no  warning,  it  is 
necessary  to  watch  them  with  great  care. 

Hepatic  abscess  I  saw  none  of,  and  the  nervous  irritation 
and  weaknes,  which  so  often  follow  injuries  of  the  head,  fell 
seldom  under  my  notice,  from  the  transference  of  the 
patients  to  the  rear  as  soon  as  their  wounds  were  healed. 
Jaundice  was  present  in  several  fatal  cases  in  which  the 
head  received  injury. 


17* 


CHAPTER  VIII. 

WOUNDS   OF   THE    FACE    AND   CHEST. 

After  the  1st  of  April,  1855,  to  the  end  of  the  war,  there  occurred  382  cases 
of  simple  flesh  contusions,  and  wounds  of  the  face  more  or  less  severe, 
and  one  death  is  classed  under  this  head.  Of  wounds  penetrating,  or 
perforating  the  bony  structure  of  this  region  without  injuring  import- 
ant organs,  there  were  107  cases,  and  10  deaths;  and  of  those  accom- 
panied by  lesion  of  important  organs,  44  cases  appear,  and  3  deaths. 
Most  of  the  fatal  results  were  owing  to  other  concurrent  causes. 

Wounds  of  the  face  have  been  interesting  chiefly  from 
the  rapidity  with  which  even  the  most  severe  and  dangerous- 
looking  of  them  heal.  The  extreme  vascularity  of  the  tissues 
of  the  face  endows  them  with  a  vitality  which  rectifies  most 
injuries,  and  the  surgeon  is  often  enabled,  both  on  this 
account  and  from  their  great  distensibility,  to  repair  the 
loss  which  has  been  sustained,  even  when  that  has  been 
very  extensive.  It  would  be  much  easier  to  say  where  and 
how  the  face  has  not  been  pierced  by  balls,  than  to  enumer- 
ate the  directions  in  which  it  has.  The  upper  and  lower 
jaws  have  been  fractured,  and  large  portions  of  them  re- 
moved, yet,  with  few  exceptions,  a  good  recovery  has 
followed,  when  no  other  concomitant  injury  assisted  to  bring 
about  an  unfavorable  issue.  One  or  other  of  the  lower 
maxilla,  anterior  to  the  masseters,  has  been  carried  away, 
and  in  one  case  which  came  under  my  notice,  but  which 
ended  fatally,  both  lower  maxillse  were  removed  by  a  round 
shot.*  The  upper  jaw  has  been  completely  destroyed,  and 

*  In  a  very  interesting  paper  read  to  the  Imperial  Academy  of 
Medicine,  by  M.  Hutin,  in  April,  1857,  there  is  an  account  given  of 
an  inmate  of  the  Invalides,  (to  which  M.  Hutin  is  surgeon-in  chief,) 
(198) 


WOUNDS   OF.  THE   FACE.  199 

in  one  case  which  occurred  in  the  31st  Regiment,  a  grape- 
shot,  seventeen  ounces  in  weight,  was  impacted  in  the 
superior  maxilla,  and  necessitated  the  removal  of  most  of 
the  bone. 

Hemorrhage  is  undoubtedly  the  great  source  of  annoy- 
ance and  danger  in  gunshot  wounds  of  the  face.  The 
difficulty  of  commanding  it  is  at  times  so  great  as  to  place 
the  patient  in  imminent  danger.  It  frequently  appears 
early,  but  stops  spontaneously.  Men  who  have  received  a 
severe  face  wound  seldom  leave  the  field  without  sustaining 
a  considerable  loss  of  blood,  and  secondary  hemorrhage  is 
common  when  the  bones  have  been  fractured.  The  depth, 
irregularity,  and  extreme  vascularity  of  the  parts  make  the 
application  of  a  ligature  to  the  bleeding^points  difficult, 
and  to  be  effectual,  compresses  must  be  applied  with  much 
niceness.  It  is  in  wounds  of  the  deep  branches  of  the  face, 
in  which  secondary  hemorrhage  has  taken  place  from  a 

who  had  the  lower  jaw  carried  away  by  a  cannon-ball  at  the  battle 
of  Wagram,  forty-eight  years  ag  >.  He  recounts  the  changes  which 
the  parts  have  undergone  since.  It  seems  that  the  hemorrhage  was 
very  severe  at  the  moment  of  injury,  but  that  it  ceased  sponta- 
neously. The  tongue  hung  down  in  front  of  the  neck,  and  was  never 
drawn  into  the  throat — an  accident  which  did  not  occur  in  four  other 
cases,  in  which  M.  Hutin  has  known  alike  injury  produced  by  alike 
cause.  The  patient  referred  to  by  M.  Hutin  has  worn  a  silver  mask 
since  his  accident,  which  protects  his  tongue  hanging  out,  and  ad- 
herent as  it  is  to  the  neck.  By  means  of  this  mask  the  variations  of 
temperature  do  not  affect  the  wide  void  which  exists  in  the  floor  of 
the  mouth.  The  most  remarkable  change  which  the  progress  of 
time  has  brought  about  in  the  parts  is,  that  the  upper  jaw,  in  place 
of  preserving  its  horseshoe  shape,  has  become  so  contracted  at  its 
middle  as  to  assume  the  figure  of  an  hour-glass.  This  change  began 
to  take  place  three  years  after  he  was  wounded,  and  has  gone  on  in- 
creasing up  to  within  a  short  time.  The  secretion  and  loss  of  saliva 
is  great,  but  the  patient  enjoys  perfect  health.  There  is  an  interest- 
ing question  raised  by  this  case,  viz.,  whether  an  analogous  change 
may  be  looked  for  in  those  instances — of  late  years  pretty  numer- 
ous— in  which  the  lower  jaw  has  been  excised. 


200  SURGERY    OP    THE    CRIMEAN    WAR. 

sloughing  surface,  that  Ariel's  operation,  performed  on  the 
main  artery,  may  be  said  to  supersede,  from  necessity,  Bell's 
doctrine  of  local  deligation. 

The  branches  of  the  facial  nerve  are  sometimes  so  much 
injured  in  wounds  of  the  face,  either  by  the  ball  or  by  the 
fractured  bone,  that  temporary  and  even  permanent  paralysis 
may  ensue ;  but  there  is  one  source  of  danger  in  these  cases 
which  does  not  always  obtain  the  attention  its  importance 
demands.  I  refer  to  the  swallowing  of  the  secretion  from 
the  wound.  If  great  care  be  not  taken  to  remove  all  the 
morbid  secretion  which  results  from  injury  of  the  bones  of 
the  face,  if  any  amount  of  it  gets  into  the  stomach,  much 
constitutional  irritation  will  result,  and  a  fever  of  a  low 
typhoid  and  very  fatal  form  will  be  caused.  I  believe  I 
have  seen  this  result  very  clearly  follow  the  cause  referred 
to  in  some  cases.  In  one  case,  where  a  sergeant  of  the 
Buffs  died  in  the  general  hospital  from  the  effects  of  a  severe 
face  injury,  by  which  the  anterior  part  of  the  lower  jaw  and 
a  small  portion  of  the  upper  were  fractured  by  a  round  shot, 
I  suspect  the  fatal  result  was  at  least  accelerated  by  the  cause 
mentioned,  although  the  utmost  care  was  taken  to  prevent 
its  occurrence.  He  was  a  very  unhealthy  man,  who  had 
just  been  discharged  from  his  regimental  hospital  a  few  days 
previous  to  the  accident,  and  was  of  a  nervous,  irritable  dis- 
position. He  was  struck  from  the  side  by  a  small  round 
shot,  which  had  previously  struck  the  parapet  of  the  trench. 
The  symphysis  and  part  of  the  body  of  the  lower  maxilla, 
as  well  as  a  small  portion  of  the  upper  jaw,  were  destroyed. 
The  soft  parts,  especially  at  the  chin,  were  much  torn  and 
bruised,  and  ultimately  sloughed.  When  examining  his 
chest,  on  account  of  a  cough  which  troubled  him  on  admis- 
sion, a  cavity  was  discovered  in  one  of  his  lungs.  Hemor- 
rhage took  place  repeatedly  from  branches  of  arteries  opened 
as  the  slough  separated.  By  maintaining  an  opening  below 
the  chin,  and  washing  the  wound  from  the  mouth,  the  greater 
part  of  the  abundant  secretion  was  removed  ;  but  yet  no 


WOUNDS   OP   THE   FACE.  201 

small  quantity  found  its  way  backward  into  the  throat,  and 
was  swallowed.  His  stomach  became  very  irritable,  his 
strength  failed,  and  a  low  muttering  delirium  preceded 
death.  A  putrid  abscess  occupied  the  summit  of  one  lung, 
and  pus  was  infiltrated  among  the  tissues  covering  the 
trachea. 

In  fractures  of  the  bones  of  the  face  from  gunshot,  we 
make  an  exception  to  the  general  rule  of  removing  frag- 
ments which  are  nearly  detached.  The  large  supply  of 
blood  which  is  sent  to  every  structure  in  this  region  enables 
pieces  of  bone  to  resume  their  full  connection  with  the  other 
tissues,  when  detached,  in  a  way  that  would  be  fatal  to  simi- 
larly placed  portions  in  other  parts.  Hence  the  rule,  not  to 
extract  any  spiculaB  whose  attachment  has  not  been  com- 
pletely destroyed,  and  whose  direction  is  not  opposed  to  a 
proper  union  of  the  broken  parts.  The  exfoliation  which 
follows  in  injuries  of  the  bones  of  the  face  is  slight  as  com- 
pared with  those  of  other  parts. 

The  destruction  or  injury  of  one  or  other  of  the  organs 
of  special  sense,  and  the  deformity  which  may  be  caused,  as 
well  as  the  tedious  exfoliations  which  at  times  follow  severe 
face  wounds,  are  the  chief  ulterior  causes  of  suffering  and 
annoyance  to  which  ttfey  give  rise.  In  cases  in  which  the 
lower  jaw  is  destroyed,  the  loss  of  bony  substance,  the 
powerful  action  of  its  muscles,  which  is  so  difficult  to 
counteract,  and  the  imperfect  mode  of  repair,  contribute  to 
occasion  a  considerable  amount  of  deformity.  It  is  a  suffi- 
ciently old  though  not  always  remembered  maxim,  to  ex- 
tract by  the  mouth,  whenever  practicable,  all  balls  lodged 
in  the  face. 

The  curious  manner  in  which  balls  may  be  concealed  in 
the  bones  of  the  face,  and  be  discharged  of  their  own  accord, 
was  shown  in  one  instance  in  the  Second  Division,  after  the 
battle  of  the  Alma.  A  round  ball  had  entered  close  to  but 
below  the  inner  canthus  of  the  eye,  and  being  lost  was 
not  further  thought  of.  The  wound  healed,  and  the  patient 


202  SURGERY   OF    THE   CRIMEAN   WAR. 

had  almost  forgotten  the  circumstance,  when,  after  suffering 
slightly  from  a  feeling  of  dryness  in  one  nostril,  the  ball  fell 
from  his  nose,  to  his  great  alarm  and  astonishment,  several 
months  afterward.  It  is  somewhat  singular  that  so  little 
trouble  should  have  been  occasioned  in  this  case,  as  it  not 
uncommonly  happens  that  a  most  distressing  fetid  suppu- 
ration attends  the  injury  of  bone  in  the  region  where  this 
ball  was  probably  lodged. 

It  is  in  wounds  of  the  neck  that  the  extraordinary  manner 
in  which  the  great  vessels  escape  a  ball's  passage  becomes 
most  evident.  Thus  the  neck  has  been  injured  by  gunshot, 
more  or  less  severely,  128  times,  and  yet  only  4  deaths  have 
resulted  from  these  wounds.  Yet  it  must  be  true  that  a 
large  number  die  on  the  field  from  these  injuries.  It  would 
be  useless,  but  sufficiently  easy,  to  record  cases  in  which 
balls,  and  even  bayonets,  have  traversed  the  neck,  and  yet 
did  not  injure  the  great  vessels ;  sometimes  passing  from 
side  to  side,  sometimes  from  before  backward,  it  would 
appear  almost  impossible  that  the  blood-vessels  could  have 
escaped  the  wounding  agent,  and  yet  no  indication  of  any 
mischief  followed.  The  great  nerves  suffer  not  uncommonly 
in  gunshot  wounds  of  the  neck,  when  such  wounds  are 
situated  low  down.  Paralysis  of  the  arm  setting  in,  either 
immediately  after  the  infliction  of  the  injury  or  a  few  days 
later,  affords  evidence  of  such  a  lesion. 

The  soft  coverings  of  the  chest  were  wounded,  after 
April  1st,  1855,  by  gunshot,  more  or  less  severely,  255  times, 
with  3  deaths  resulting.  In  24  cases,  the  bony,  cartilagin- 
ous, or  intercostal  tissues  were  wounded,  and  one  of  these 
died.  Lesion  of  the  contents  took  place  16  times,  although 
the  ball  did  not  penetrate,  and  9  deaths  resulted  from  that 
cause.  The  ball  penetrated  and  logded,  or  appeared  to 
lodge,  33  times,  and  of  these  patients  31  perished,  while  in 
9  cases  the  contents  of  the  thorax  were  wounded  superfi- 
cially, 3  times  with  a  fatal  result.  In  83  instances  the  con- 


WOUNDS  OF  THE  FACE  AND  CHEST.         203 

tents  were  deeply  perforated,  and  death  followed  in  71  cases.* 
It  would  thus  appear  that,  with  all  our  boasted  improvements 
in  the  method  of  investigating  the  effect  and  progress  of  in- 
juries of  the  lungs,  the  mortality  has  not  abated  much  from 
what  it  has  always  been,  when  large  numbers  of  men  have 
sustained  such  injury  from  gunshot.  Wounds  of  the  thorax 
are  very  common  in  battle  when  the  combatants  are  in  close 
proximity.  This  was  particularly  the  case  in  the  civil  dis- 
turbances in  Paris;  and  in  siege  operations  the  same  holds 
good.  The  large  surface  and  elevated  position  of  the  thorax 
accounts  in  some  measure  for  this. 

The  distinction  usually  made  between  wounds  of  the 
parietes  and  those  which  penetrate  and  injure  the  viscera  of 
the  cavity  is  evidently  a  good  one,  as  it  separates  between 
two  classes  of  injuries  of  very  different  import. 

Simple  contusion  of  the  walls  may  be  caused  by  a  spent 
ball,  or  by  a  ball  which  has  impinged  against  some  part  of 
the  soldier's  accoutrements,  and  has  thus  been  prevented 
from  entering.  Such  an  injury,  although  not  accompanied 
by  any  fracture,  may  yet  be  sufficient  to  give  rise  to  haemop- 
tysis, severe  constitutional  shock,  and  internal  inflammation. 
If  the  ball  strike  the  edge  of  any  of  the  metal  plates  which 

*  M.  Legouest  mentions,  in  a  communication  he  has  been  good 
enough  to  send  me,  (5  cases  of  penetrating  wounds  of  the  chest,  as 
having  occurred  in  his  division  of  the  Dolma  Batch!  hospital  at  Con- 
stantinople, and  of  these  the  half  died.  Alcock  gives  1  to  l,,^ 
as  the  mortality  attending  his  cases  of  penetrating  and  perforating 
gunshot  wounds  of  the  thorax.  In  Guthrie's  106  cases,  of  whom  a 
half  perished,  "the  cavities  were  not  penetrated."  In  the  documents 
of  the  medical  department  I  have  found  a  record  of  30  cases  in  which 
the  chest  was  penetrated,  and  in  some  perforated  by  balls.  In  most 
of  these  there  were  signs  of  injury  to  the  contents.  Of  these  89  cases, 
27  died  and  12  recovered.  Meniere  reports  20  cases  of  perforating 
wounds  by  gunshot,  many  of  them  effected  at  very  short  range.  All 
died,  many  very  soon  afier  being  wounded.  Nine  penetrating  wounds 
which  he  also  mentions  recovered,  in  all  which  there  were  signs  of 
lesion  of  the  lungs. 


204  SURGERY   OF   THE   CRIMEAN    WAR. 

form  part  of  the  soldier's  accoutrements,  then  the  injury  to 
the  contents  may  be  inflicted  by  the  part  so  struck,  as  was 
the  case  in  the  following  instance,  in  which  a  round  shot 
was  the  missile,  and  the  seventy  of  the  injury  was  little 
evidenced  by  the  symptoms  before  death  :  Darling,  private, 
61st  Regiment,*  was  hit  at  Sadoolapore  by  a  round  shot, 
on  the  edge  of  the  breast-plate,  which  was  so  turned  inward 
as  to  fracture  the  cartilages  of  the  fifth,  sixth,  and  seventh 
ribs  on  the  left  side,  close  to  the  sternum.  The  skin  was 
not  wounded.  He  walked  to  the  rear,  and  complained  but 
little  for  two  hours,  when  he  was  seized  with  an  acute  pain 
in  the  region  of  the  heart.  His  pulse  became  much  accel- 
erated, and  he  grew  faint  and  collapsed.  A  distinct  and 
sharp  bellow's-sound  accompanied  the  heart's  action.  He 
died  in  seventy-two  hours  from  the  receipt  of  the  injury — 
the  pain  and  dyspnoea,  which  had  been  so  urgent  at  first, 
having  abated  for  some  hours  before  death.  The  heart  Was 
found  to  have  been  ruptured  to  an  extent  sufficient  to  allow 
of  the  finger  being  thrust  into  the  left  ventricle.  The  obli- 
quity of  the  opening  had  prevented  the  blood  escaping  into 
the  pericardium,  which  contained  about  two  ounces  of  dark- 
colored  serum. 

Dupuytren  has  drawn  attention  to  the  long  period  which 
ball  wounds  of  the  soft  parietes  of  the  chest  take  to  heal, 
especially  when  they  are  "en  gouttiere."  This  he  accounts 
for  by  the  constant  motion  imparted  to  the  walls  by  the 
movements  of  respiration. 

If  the  blow  from  a  ball  be  forcible,  or  strike  directly  on 
the  chest  without  the  intervention  of  any  strong  substance, 
then  fracture  of  one  or  more  of  the  ribs  will  probably  be 
caused,  and  possibly  pleural  or  visceral  inflammation  as 
well,  from  the  effects  of  the  blow,  or  the  presence  of  spiculae 
driven  inward.  These  fragments  are  at  times  long  and 
sharp,  and  may  be  totally  detached  from  the  rib,  and  carried 

*  Unpublished  records  of  the  Medical  Department. 


WOUNDS  OF  THE  FACE  AND  CHEST.        205 

deeply  into  the  lung  substance.  The  cartilage  of  a  rib, 
although  torn  by  a  ball,  is  seldom  driven  into  the  parenchy- 
matous  tissue,  but  remains  so  attached  that  its  fragments 
can  be  easily  restored  to  their  proper  position. 

It  occasionally  happens  that  a  ball  is  arrested  between 
two  ribs.  This  happened  in  the  following  case :  Cassay,  a 
private  in  the  38th  Regiment,  was  admitted  under  my 
charge,  into  the  general  hospital,  on  the  18th  of  June,  suf- 
fering from  a  gunshot  wound  of  the  left  side  of  the  thorax. 
The  ball,  a  large  conical  one  with  a  broad  base,  was  much 
spent  when  it  struck  him.  It  did  not  force  itself  into  the 
cavity,  but  lay  wedged  between  the  cartilages  of  the  second 
and  third  ribs,  on  the  left  side,  about  an  inch  from  the  ster- 
num. On  withdrawing  the  ball,  the  cavity  of  the  chest  was 
found  to  be  fairly  opened,  and  the  lung  was  visible  as  it  ex- 
panded and  contracted.  The  patient  had  a  severe  attack  of 
pleurisy  a  few  days  afterward,  for  which  he  was  repeatedly 
bled.  Effusion,  to  a  limited  extent,  followed,  and  his  gums 
were  touched  with  mercury.  For  five  weeks  the  wound 
continued  to  suppurate  freely.  The  lung  became  adherent 
to  the  parietes.  This  patient  had  subsequently  a  short 
attack  of  bronchitis,  but  ultimately  made  a  good  recovery. 
He  went  to  England  in  August,  at  which  time  he  still  com- 
plained of  a  severe  pain  in  the  left  clavicle  and  shoulder, 
which  extended  down  to  his  hand,  and  was  attended  by 
numbness  and  want  of  power.  The  pain  was  increased  by 
touching  the  arm,  and  had  continued  since  he  was  wounded. 
In  this  case  the  cavity  was  opened,  but  the  lung  escaped  in- 
jury. The  non-collapse  of  the  lung  was  well  seen  in  this,  as 
in  some  other  instances  which  fell  under  my  notice.  The 
natural  mode  of  repair,  by  adhesion  between  the  lung  and 
the  walls  of  the  chest,*  and  the  troublesome  affection  arising 

*  The  advantage  of  this  adhesion  of  the  pleurae,  and  the  part 
•which  it  plays  in  the  repair  of  chest  wounds,  is  well  brought  out  by 
Roux  in  his  Melanges  de  Chirurgie. 

18 


206  SURGERY   OF   THE   CRIMEAN    WAR. 

from  injury  to  the  nerves  of  the  arm,  were  both  illustrated  in 
the  above  case. 

Pieces  of  shell  not  unfrequently  open  the  cavity,  but 
spare  the  lung,  while  sometimes  the  reverse  happens,  and 
the  lung  may  be  injured  without  the  pleural  sac  being 
opened.  The  following  was  a  curious  instance  of  this  latter 
accident,  without  the  thorax  being  opened.  The  case  oc- 
curred under  the  charge  of  my  friend  Mr  J.  H.  Hulke, 
assistant-surgeon  to  King's  College  Hospital,  to  whom  I  am 
indebted  for  the  details :  Private  Jeremiah  O'Brien  was  ad- 
mitted into  the  general  hospital  on  the  15th  November,  1855, 
having  been  wounded  by  a  piece  of  shell  when  the  right 
siege-train  exploded.  His  left  arm  and  forearm  were  ex- 
tensively shattered,  and  he  had  two  small  irregular  wounds 
on  the  left  side  of  his  chest,  one  just  below  the  lower  angle 
of  the  shoulder-blade,  and  the  other  on  the  same  level,  but 
about  two  inches  nearer  the  sternum.  His  breathing  was 
quick  and  labored,  and  bright  florid  blood  was  bubbling 
from  his  mouth.  His  face  was  pale,  his  pulse  flickering  and 
very  feeble.  He  spoke  with  a  firm  voice,  and  begged  his 
arm  to  be  cut  off.  No  communication  could  be  detected 
between  the  wounds  on  the  chest  and  the  cavity  within,  but 
two  ribs  were  found  to  be  broken.  His  wounds  were  dressed 
simply,  and  his  chest  fixed.  Beyond  dressing,  nothing  was 
done  to  the  arm,  as  he  was  not  in  a  condition  to  undergo 
any  operation.  By  night  the  breathing  was  easier,  and  he 
brought  up  less  blood.  Next  morning  his  pulse  was  fuller, 
but  intermittent.  His  spit  still  contained  blood.  His  chest 
was  naturally  resonant  as  low  as  the  fourth  rib,  but  below 
this,  by  percussion  and  auscultation,  dullness  and  friction 
sounds  were  discovered.  He  was  cheerful,  but,  as  he  had 
not  slept,  half  a 'grain  of  morphia  was  adminiscered.  He 
subsequently  rallied  somewhat,  but  died  suddenly  next  after- 
noon, without  any  return  of  the  bleeding.  On  examination 
after  death,  the  sixth  and  seventh  ribs  were  found  fractured 
without  displacement.  The  pleura  costalis  was  entire.  The 


WOUNDS  OF  THE  FACE  AND  CHEST.        201 

part  of  the  lung  below  the  level  of  the  fracture  was  entirely 
adherent  to  the  ribs  and  diaphragm,  while  in  the  upper  part 
of  the  pleura!  sac  a  small  quantity  of  bloody  serum  was 
found.  Opposite  the  position  of  the  fractured  ribs,  the  lung 
substance  was  extensively  lacerated.  A  large  rent  ran 
inward  from  the  external  surface  toward  the  root,  downward 
toward  the  base,  and  upward  toward  the  apex.  A  large 
branch  of  the  pulmonary  artery  was  seen  with  an  open  torn 
mouth  in  the  rent,  while  many  other  vessels  stretched  across 
it.  The  right  or  uninjured  lung  was  ecchymosed  at  numerous 
spots  on  its  surface,  and  in  part  emphysematous.  Ecchy- 
mosed points  were  seen  also  on  the  surface  of  the  heart  and 
pericardium.  The  mitral  valves  and  endocardium  of  the 
left  ventricle  were  of  a  rosy  hue.  The  segments  of  the  tri- 
cuspid  valve  were  bound  together  by  a  fibrinous  clot,  which 
narrowed  the  passage  to  the  size  of  a  small  quill.  Blood 
was  found  in  the  small  intestines,  but  not  in  the  stomach. 
Mr.  Hulke  remarks  the  arrestment  of  the  bleeding  by  the 
mode  in  which  the  chief  vessel  was  torn,  as  well  as  the  con- 
servative act  of  shutting  off  the  rent  in  the  lung,  and  the 
torn  bronchi  from  the  pleural  sac  by  the  formation  of 
adhesions. 

It  is  seldom  that  a  conical  ball  will  be  found  to  lodge  in  a 
rib,  as  a  round  one  has  been  seen  to  do,  or  yet  to  run  round 
under  the  integuments,  or  at  all  to  lodge  within  the  chest. 
In  fact,  it  very  rarely  fails  to  penetrate  deeply,  or  pass  quite 
through  the  entire  cavity. 

Non-penetrating  wounds  are  more  dangerous  at  some 
points  of  the  thorax  than  at  others.  Thus,  when  a  ball 
strikes  a  large  bone  like  the  scapula  or  the  spine,  or  in  those 
places  where  the  large  blood-vessels  and  nerves  are  situated, 
as  in  the  axilla  and  upper  part  of  the  chest,  the  danger  is 
greatly  increased. 

The  gravity  of  penetrating  wounds  depends  very  much 
on  their  direction  and  their  point  of  entrance,  as  when,  with 
an  incidence  very  oblique  to  the  surface,  they  enter  at  some 


208  SURGERY   OF   THE   CRIMEAN    AVAR. 

parts  of  the  chest,  they  may  traverse  a  portion  of  the  cavity 
without  touching  the  contents.  So  it  happened  in  the  fol- 
lowing case  :  Fontaine,  a  private  in  the  90th,  wounded  on 
the  8th  September,  was  admitted  into  the  general  hospital 
on  the  same  day.  The  ball,  after  passing  through  the  flesh 
of  his  left  arm,  which  was  at  the  moment  in  advance  of  his 
body,  had  entered  the  thorax  in  the  axilla,  and  escaped  at 
the  inferior  angle  of  the  scapula,  fracturing  it,  along  with 
two  of  the  ribs,  at  the  place  of  exit.  No  immediate  disturb- 
ance followed,  but  in  twenty-four  hours  signs  of  acute  pleu- 
risy appeared,  and  required  decided  treatment.  The  ball 
had  entered  the  cavity  of  the  chest,  but  the  substance  of  the 
lung  had  evidently  escaped.  Bone  exfoliated  by  the  wound 
of  exit,  which  continued  to  suppurate  long  after  that  of 
entrance  had  closed.  No  bad  symptom  arose  after  the 
attack  of  pleurisy  above  referred  to  was  subdued.  I  have 
seen  this  man  lately  in  perfect  health. 

The  finger  is  the  only  probe  permissible  in  examining 
wounds  of  the  thorax,  if  we  thereby  discover  the  projec- 
tion inward  of  fragments  of  a  rib,  or  portions  of  it  impacted 
in  the  lung,  we  should  take  immediate  steps  for  their  removal, 
even  though  the  wound  has  to  be  enlarged  in  order  to  allow 
of  its  accomplishment.  The  ribs  are  best  fixed,  and  the 
wound  left  free,  by  means  of  strips  of  adhesive  plaster 
passed  from  the  spine  to  the  sternum,  and  from  above  down- 
ward, so  placed  as  to  embrace  the  wounded  side  only.  Men 
wounded  in  the  lungs  require  all  the  breathing  space  we  can 
give  them,  and  this  is  best  managed  by  having  the  sound 
side  free. 

It  is  a  singular  circumstance  connected  with  wounds  of 
the  walls  of  the  thorax,  that  an  intercostal  artery  is  seldom 
opened.  I  neither  saw  nor  heard  of  such  a  case  during  the 
war,  so  that  we  were  spared  the  adoption  of  any  of  those 
operative  procedures  for  its  closure,  which,  Boyer  remarks, 
are  more  numerous  than  the  authentic  cases  of  the  occur- 
rence of  the  accident. 


WOUNDS  OF  THE  FACE  AND  CHEST.         209 

Balls  passing  in  front  of  the  chest  from  side  to  side  may 
cause  very  grave  injury  to  the  parietes,  without  absolutely 
wounding  either  the  heart  or  lungs.  This  occurred  in  the 
following  most  interesting  case : — 

Fleming,  a  private  in  the  18th  Regiment,  was  admitted 
on  the  18th  of  June  into  the  general  hospital,  under  Mr. 
Rooke.  This  lad  was  struck  by  a  Minie  ball,  a  little  above 
the  right  nipple,  as  he  stood  sideways  toward  the  enemy. 
The  ball  escaped  below  the  left  breast.  The  sternum  was 
fractured  and  comminuted  by  the  ball  in  its  transit.  Severe 
dyspnoea  followed,  together  with  a  slight  attack  of  haemop- 
tysis. Repeated  attacks  of  inflammation  occurred  over 
parts  of  both  lungs,  and  the  subsequent  supervention  of 
pericarditis  necessitated  bleeding  and  the  use  of  tartar 
emetic,  and  subsequently  of  mercury,,  so  as  to  touch  the 
gums.  The  soft  parts  between  the  wounds  of  entrance  and 
exit  sloughed,  and  the  sternum,  to  the  extent  of  about  one 
and  a  half  inches,  together  with  the  cartilaginous  ends  of 
the  ribs  thereto  attached,  came  away  in  fragments,  or  were 
absorbed,  so  that  by  the  12th  of  July  a  profusely  suppura- 
ting wound  had  formed,  6  inches  long  by  2J  broad,  across 
the  front  of  the  chest,  laying  open  the  anterior  mediastinum, 
together  with  the  right  thoracic  cavity,  the  opening  into 
which  was,  however,  sealed  by  the  adhesion  of  the  lung  to 
the  parietes.  At  the  left  extremity  of  the  wound,  and  at 
its  lower  part,  the  heart  was  plainly  felt  only  covered  by  the 
pericardium.  A  to-and-fro  sound  accompanied  the  motions 
of  the  heart,  but  these  were  not  sufficiently  pronounced  to 
prevent  the  recognition  of  the  two  natural  notes.  Hectic 
fever,  harassing  cough,  and  emaciation  supervened.  By  the 
middle  of  July  the  wound  had  begun  to  granulate,  and  the 
patient  seemed  to  improve.  An  attack  of  diarrhoea,  how- 
ever, prostrated  his  little  remaining  strength,  and  ultimately 
proved  fatal.  Before  death,  the  pus  with  which  the  wound 
was  filled  receded  on  inspiration,  and  welled  up  when  the 
lungs  were  emptied,  as  if  it  sank  between  the  lungs  when 

18* 


210  SURGERY    OF   THE   CRIMEAN    WAR. 

they  expanded.  On  the  morning  of  the  day  on  which  he 
died,  a  new  sound  was  heard  to  proceed  from  the  region  of 
the  heart,  to  which  we  never  before  heard  any  similar.  It 
was  exactly  like  the  "clanking"  note  which  accompanies 
the  working  of  a  pump  when  its  gear  is  loose.  There  was 
the  sucking  in  and  expulsion  sound,  together  with  this  sharp, 
peculiar  note,  which  it  is  impossible  to  describe,  but  which 
immediately  suggested  the  probability  that  the  pericardium 
had  been  opened,  and  that  the  pus  which  filled  the  wound 
was  alternately  being  sucked  into  and  ejected  from  its  cavity. 
On  examination,  this  view  was  confirmed,  as  a  small  hole  was 
found  at  the  inferior  and  left  lateral  aspect  of  the  wound, 
through  which  the  pus  appeared  to  be  drawn  in  and  thrown 
out  during  the  action  of  the  heart.  After  death  it  was 
found  that  this  aperture  led  into  the  pericardium,  which  was 
much  thickened,  and  adherent  to  the  heart  for  a  space  of 
two  inches  by  one,  at  the  anterior  and  middle  part  of  that 
organ.  The  opening  mentioned  led  into  a  pouch  formed  by 
the  pericardium  round  the  roots  of  the  great  vessels,  and 
which  pouch  communicated  freely  on  the  right  side  of  the 
heart  with  the  sac  of  the  pericardium,  at  the  base  of  the 
heart  below  the  adhesion.  Pus  was  freely  effused  into  the 
pericardium,  and  the  surface  of  that  membrane,  as  well  as 
that  of  the  heart,  was  of  a  drab  color  and  thickly  coated 
with  lymph  of  a  low  type  of  organization.  The  heart  itself 
was  healthy.  The  lungs  were  somewhat  congested,  and 
their  anterior  surfaces  were  adherent  to  the  parietes.  The 
coats  of  the  stomach  were  unhealthy,  but  beyond  this  nothing 
was  observed. 

The  noble  struggle  made  against  death  by  this  poor  boy, 
the  very  extensive  injury,  the  opening  of  the  pericardium, 
and  the  sealing  of  both  sides  of  the  thorax  by  the  pleural 
adhesions,  were  all  points  of  much  interest  and  no  little 
instruction.* 

*  John  Bell  (second  Discourse  on  Wounds,  p.  302)  refers  to  a  case 
related  by  Galen,  in  which  part  of  the  sternum  was  removed,  the 


WOUNDS    OF    THE    FACE    AND    CHEST.  211 

The  two  following  cases  show  how  small  a  difference  in 
the  place  of  transit  of  the  ball  may  determine  the  question 
of  life  or  death  :  A  Zouave  was  struck  at  the  Alma  by  a 
round  ball,  which  entered  the  parietes  close  to  the  right  nip- 
ple, and  escaped  at  a  corresponding  point  on  the  left  side. 
The  ball  passed  in  front  of  the  sternum,  which  it  fractured. 
Curiously  enough  no  inflammation  whatever  of  the  contents 
of  the  thorax  followed,  and  he  was  in  a  short  time  discharged 
well.  The  points  of  entrance  and  exit  differed  little  in  this 
and  in  the  case  of  Fleming,  but  the  projection  of  the  sternum 
being  less  in  this  patient  the  result  was  very  different. 

A  Russian  soldier  lay  close  to  the  Zouave  just  referred  to, 
who,  in  the  same  battle,  had  been  struck  by  a  ball  about  a 
quarter  of  an  inch  to  the  outside  of  the  right  nipple.  The 
ball  had  then  passed  behind  the  sternum,  fracturing  it  badly 
in  its  course,  and  escaped  close  to  the  left  nipple.  Double 
pneumonia  and  pericarditis  followed,  and  he  died.  The 
whole  contents  of  the  thorax  were  found  implicated  in  one 
vast  inflammation.  Not  being  present  at  the  post-mortem 
examination,  I  did  not  learn  how  far  the  pleura  or  pericar- 
dium were  injured  (as  1  understood  they  were)  primarily. 

When  a  ball  fairly  enters  the  chest,  and  either  penetrates 
or  traverses  the  lung,  the  danger  is  most  imminent.  These 
injuries,  however,  are  not  so  fatal,  on  the  whole,  as  similar 
wounds  of  the  head  or  the  abdomen.  The  younger  Larrey* 
and  Meniere  both  record  the  circumstance,  that  the  majority 

pericardium  opened,  and  the  man  cured.  He  thus  comments  upon 
it:  "IJore,  then,  we  have,  upon  that  authority  which  has  been 
always  respected,  a  case  exceeding  in  the  miraculous  all  that  has 
ever  been  recorded  by  the  patient  Vander  Wiel,  or  gathered  by 
Schenkius,  or  any  German  commentator  among  them — a  man  with  a 
slow  .suppuration,  confined  matter,  a  cnrious  sternum,  and  the  heart 
absolutely  exposed  and  bare."  In  Fleming's  case  we  had  all  tie 
unfavorable  symptoms,  but,  unfortunately,  not  the  recovery. 

*  Relation  Chirurgicale  dcs  Eve'nenients  de  Juillet,  1830,  a  1'hopi- 
tal  militaire  du  Gros-caillou. 


212          SURGERY  OF  THE  CRIMEAN  WAR. 

of  the  killed  in  the  civil  commotions  of  1830,  in  Paris,  suc- 
cumbed from  penetrating  wounds  of  the  thorax.  The  im- 
mediate danger  will  depend  upon  the  depth  of  penetration, 
and  the  part  implicated.  If  the  heart  or  great  vessels  are 
wounded,  death  will  in  general  be  instantaneous.*  When 
the  lung  is  only  superficially  wounded,  then  the  vessels  which 
are  injured  must  be  of  small  caliber ;  but  the  deeper  the 
ball  penetrates,  the  larger  are  those  encountered,  and,  con- 
sequently, the  more  mortal  is  the  wound.  The  patient  may 
be  suffocated  at  once  by  the  blood,  or  it  may  escape  in  such 
quantity  as  to  cause  death,  within  a  short  time,  by  exhaus- 
tion. If  the  wound  be  at  all  severe,  the  shock  is  very  great, 
and  blood  generally  passes  from  both  the  mouth  and  the 
wound.  That  from  the  mouth  is  frothy,  while  that  from  the 
wound  is  darker  colored  in  general.  The  wound  being  high 
in  the  walls  of  the  thorax  will  make  the  escape  of  blood  by 
the  orifice  less  in  quantity  than  if  it  be  situated  low  down, 
and  such  a  situation  will  render  the  evacuation  of  the  effused 
blood  or  serum  more  difficult  afterward.  Air  as  well  as 
blood  will  generally  escape  by  the  wound,  and  thus  the  pres- 
ence of  these  two  signs — blood  by  the  mouth,  and  blood  and 
air  by  the  wound  —  are  unequivocal  proofs  that  the  lungs 
have  been  injured,  although  their  absence  does  not  prove 
the  opposite,  f 

The  dangers  which  attend  a  penetrating  wound  of  the 
lung  are  thus,  primarily,  hemorrhage  and  collapse,  as  well 
as  those  from  suffocation,  if  the  bleeding  be  profuse.  The 
hemorrhage  and  the  fainting  are,  by  a  sort  of  paradox,  both 
the  patient's  danger  and  his  safety.  Secondarily,  the  danger 

*  In  the  New  York  Journal  of  Medicine,  vol.  xiv.,  there  is  a  very 
interesting  paper,  by  Dr.  Purple,  on  wounds  of  the  heart.  He  makes 
reference  to  several  cases  in  which  balls  have  remained  long  imbedded 
in  that  organ. 

j-  In  the  accounts  given  us  of  the  spear  wound  which  so  nearly 
deprived  Alexander  the  Great  of  his  life,  in  the  battle  with  the  Malli, 
we  are  told  that  he  blew  both  air  and  blood  from  his  wound. 


WOUNDS   OP   THE   FACE    AND   CHEST.  213 

of  such  wounds  proceeds  from  inflammation  and  its  products, 
the  exhaustion  which  attends  prolonged  exfoliations  and  sup- 
puration, together  with  that  which  arises  from  the  organic 
diseases  that  are  thereby  so  apt  to  be  engendered. 

A  short,  tickling,  harassing  cough,  attended  by  bloody 
expectoration  ;  a  cold  and  bedewed  surface ;  a  pale,  anxious 
face ;  a  weak,  trembling  pulse ;  palpitations  of  the  heart ; 
oppressed  breathing,  arising  in  the  first  instance,  according 
to  Hunter,  from  the  pain  occasioned  by  the  action  of  the 
wounded  lung  and  muscles,  and  afterward  from  the  inflam- 
mation and  effusion, — these  are  the  usual  symptoms  which 
attend  penetrating  wounds  of  the  lungs.  At  a  later  date, 
if  the  bleeding  cease  —  a  circumstance  which  will  be  evi- 
denced by  the  disappearance  of  the  collapse,  the  return  of 
the  heat  to  the  surface,  and  of  strength  to  the  pulse,  as  well 
as  by  the  length  of  time  which  has  elapsed  since  the  inflic- 
tion of  the  wound — then  those  symptoms  which  result  from 
inflammation  appear.  We  have  thus  two  stages  or  periods 
which  demand  separate  attention  in  our  treatment — that 
during  which  there  is  internal  hemorrhage  with  collapse, 
and  that  which  follows  and  is  accompanied  by  reaction  and 
inflammatory  action ;  to  these  I  might  also  add  that  of  con- 
valescence. 

The  collapse  which  follows  penetrating  wounds  of  the 
lung,  though  dangerous,  is  yet,  if  not  very  profound  or 
prolonged,  the  best  guarantee  for  the  patient's  safety.  To 
such  cases  the  observation  of  Hewson  is  peculiarly  applica- 
ble :  "  Languor  and  faintness,  being  favorable  to  the  con- 
gelation of  the  blood  and  to  .the  contraction  of  the  bleeding 
orifices,  should  not  be  counteracted  by  stimulating  medicines, 
but,  on  the  contrary,  should  be  encouraged."  With  our 
modern  notions  on  bleeding,  it  is  often  difficult  to  reconcile 
the  necessity,  which  experience  shows  there  is,  for  energetic 
depletion  when  reaction  sets  in.  The  majority  of  our  pa- 
tients were  certainly  not  subjects  in  which  this  remedy  could 
be  pushed  so  far  as  Guthrie  and  Hennen  would  appear  to 


214  SURGERY   OF   THE   CRIMEAN    WAR. 

recommend  ;  but  I  think  it  was  very  generally  observed  that 
those  cases  did  best  in  which  early,  active,  and  repeated 
bleedings  were  had  recourse  to.  It  is  well  known  that  in 
sieges  generally  soldiers  do  not  show  their  usual  tolerance 
of  bleeding,  and  when  their  health  is  so  much  undermined 
as  it  was  at  Sebastopol,  the  surgeon  is  often  placed  in  a 
most  unpleasant  dilemma.  That  many  most  excellent  re- 
coveries were  made  without  having  recourse  to  the  lancet,  is 
undoubtedly  true ;  but  not  a  few,  I  fear,  died  from  want  of 
it.  When  the  loss  of  blood  by  expectoration  and  by  the 
wound  has  been  very  free,  of  course  the  necessity  for  ab- 
stracting it  otherwise  will  be  much  less.  The  system  is  then 
far  more  easily  reduced  to  that  point  which  favors  the  forma- 
tion of  the  "caillot  tutelaire."  We  must,  in  cases  where 
venesection  is  required,  be  especially  careful  to  bleed  by  a 
large  orifice,  and  be  guided  by  effects.*  This,  with  perfect 
rest,  the  lowest  diet,  cooling  drinks,  and  possibly  digitalis, 
must  form  our  means  of  managing  the  early  stage.  Any 
return  of  the  oppression  will  show  the  necessity  for  further 
depletion.  In  wounds  from  gunshot,  the  patient  should  be 
allowed  to  lie  in  the  position  which  he  chooses ;  but  if  the 
wound  be  a  stab,  the  position  prescribed  should  be  that 
which  will  favor  the  adhesion  of  the  pleurae  ;  and  when  there 
is  effusion  within  the  thorax,  that  which  will  allow  of  its 
escape. 

To  determine  whether  the  blood  which  flows  from  a  wound 
in  the  thorax  proceeds  from  a  wounded  intercostal  or  from 

*  "  Until  the  danger  of  immediate  death  from  hemorrhage  is  over," 
says  Hennen,  "  we  must  not  think  of  employing  anything  except  de- 
pletion by  the  lancet ;  it,  and  it  only,  can  save  the  life  of  the  wounded 
man."  "It  is  only  by  these  repeated  bleedings,"  says  John  Bell, 
"that  the  patient  can  be  saved.  The  vascular  system  must  be  kept 
low  in  action,  and  so  drained  as  to  prevent  the  lungs  from  being  op- 
pressed with  blood.  One  thing  is  very  clear,"  he  adds,  "that  if  the 
surgeon  bleed  only  when  the  cough  and  bleeding  from  the  lungs 
return,  he  never  can  do  wrong." 


WOUNDS  OF  THE  FACE  AND  CHEST.         215 

the  lung",  has  called  forth  more  acumen  and  research  than  it 
would  appear  to  merit.  The  difficulty  will  be  greatest  when 
a  knife  has  been  the  instrument,  and  the  wound  made  is  very 
oblique.  In  large  wounds,  Sanson  lays  down  the  following 
means  of  diagnosis :  1.  Whether  the  blood  be  arterial  or 
venous.  2.  By  turning  out  with  forceps  the  lips  of  the 
wound,  and  seeing  whether  the  blood  proceeds  from  one  of 
these  lips.  3.  By  compressing  the  superior  lip  of  the  wound 
with  the  finger,  i.e.  pressing  upon  the  inferior  border  of  the 
upper  rib,  where  the  wounded  intercostal  may  be  placed. 
He  objects  to  the  use  of  a  roll  of  card  introduced  in  the 
shape  of  a  gutter,  because  when  that  can  be  done  we  may 
be  able  to  see  the  wounded  vessel  with  the  eye  ;  but  the 
examination  of  the  wounding  instrument  will  often  show 
whether  it  could  penetrate  deep  enough  to  injure  the  lung. 

Bleeding  from  the  lung  makes  itself  apparent  by  both 
rational  and  physical  signs.  Some  of  these  are  common 
to  all  hemorrhages,  external  or  internal,  while  others  are 
present  in  intra-thoracic  effusions  of  whatever  description. 
Of  the  rational  signs,  paleness  of  the  face,  coldness  of  the 
surface,  a  small,  concentrated,  and  quick  pulse,  giddiness,  and 
syncope  are  those  referable  to  the  loss  of  blood  ;  while  the 
dyspnoea,*  sometimes  amounting  almost  to  suffocation,  the 
feeling  of  weight  in  the  chest,  the  anxiety,  restlessness,  and 
the  decubitus  on  the  wounded  side  belong  to  all  effusions. 
The  physical  signs  are  also  common  to  all  effusions.  They 
are — a  dilated  chest,  little  moved  during  respiration,  bulged 
intercostal  spaces,  dullness  on  percussion,  and  the  absence 
of  vesicular  breathing.  If  there  be  air  also  present,  we  will 
have  added  those  signs  which  are  peculiar  to  such  a  com- 
plication, and  which  are  recognizable  by  percussion  and 
auscultation.  The  peculiar  ecchymosis  described  by  Yalen- 
tin,  and  which  results  from  the  escape  of  blood  into  the  sub- 

*  Sabatiev  mentions  having  seen  patients  perish  of  hemorrhagic 
effusion  in  whom  the  breathing  was  not  disturbed,  and  who  could  lie 
in  any  position. 


216  SURGERY    OF    THE    CRIMEAN    WAR. 

cutaneous  cellular  tissue,  seldom  appears  ;  but  if  it  does,  it 
is  according  to  many  a  valuable  sign  of  hemorrhagic  effusion.* 
If,  then,  after  a  gunshot  wound  of  the  thorax,  we  have  those 
signs  present  which  would  indicate  the  loss  of  blood,  as  well 
as  those  which  indicate  the  existence  of  fluid  in  the  pleura, 
embarrassing  the  functions  of  the  contained  viscera,  the 
diagnosis  is  plain.  If  blood  escape  by  the  external  wound 
during  respiration,  or  after  a  cough,  the  opinion  will  be 
strengthened  that  blood  has  been  poured  out,  and  occupies 
the  pleural  sac. 

The  danger  from  hemorrhage  is  greatest  during  the  first 
twelve  hours,  and  is  pretty  well  over  by  the  second  day.  A 
flow  may,  however,  continue,  in  greater  or  less  quantity,  for 
eight  or  ten  days,  but  then  it  is  seldom  to  any  serious 
amount.  If  the  quantity  of  blood  effused  be  small,  it  will 
probably  be  absorbed ;  but  if  it  is  in  large  quantity,  and 
especially  if  air  is  also  present,  the  gravity  of  the  lesion  is 
much  augmented.  So  soon  as  all  fear  of  a  renewal  of  the 
bleeding  is  over,  the  effused  blood,  if  in  quantity,  should  be 
evacuated  by  operation  ;  but,  as  Sanson  says,  it  is  better  to 
be  a  little  late  than  too  early  in  taking  this  step.f 

*  Luez  remarks  upon  this  point :  "  Valentin  pretends  that  the 
ecchymosis  which  is  observed  on  the  loins,  in  wounds  of  the  thorax, 
is  a  pathognomonic  symptom  of  effusion  into  the  pleura,  and  that  its 
absence  is  a  counter-indication  to  paracentesis.  Larrey  says  he  con- 
stantly observed  this  fact,  as  do  many  other  practitioners,  such  as 
Louis,  David,  etc.  However,  after  the  observations  collected  by  De- 
granges,  Chaussier,  Callisen,  Saucerotte,  and  others,  we  cannot  look 
upon  this  phenomenon  as  a  certain  sign  of  hemo-thorax ;  because,  in 
many  circumstances  where  the  effusion  really  exists,  it  has  not  been 
observed,  and  it  has  followed  non-penetraling  wounds." 

f  "Au  reste  cette  indication  n'est  que  d'une  importance  tout-a-fait 
secondaire  quand  on  la  compare  a  celle  qui  prescrit  d'arreter  a  tout 
prix  I'hsemorrhagie  ;  aussi  avant  de  pratiquer  une  nouvelle  ouverture 
on  d'agrandir  celle  qui  existat  deja,  convient-il  de  s'assurer  si 
1'ecoulement  du  sang  hors  dn  vaisseau  divise"  a  cesse  completement. 
Hors  de  cette  condition,  1'operation  n'aurait  d'autre  resultat  que  de 


WOUNDS   OF   THE   CHEST.  217 

There  is  no  question  connected  with  wounds  of  the  chest 
so  difficult  to  solve  as  that  which  has  reference  to  the  man- 
agement of  internal  hemorrhage.  The  embarrassed  state  of 
the  lung  demands  the  evacuation  of  the  fluid  ;  and  yet,  if 
we  allow  it  to  escape,  the  bleeding  from  the  lung  is  renewed, 
and  death  results.  So  it  was  in  the  following  case  : — 

Hannihan,  a  private  in  the  Royal  Irish  Regiment,  was 
admitted  into  my  wards  in  the  general  hospital  on  the  18th 
of  June.  While  lying  on  the  ground,  with  his  head  toward 
the  enemy,  he  was  struck  above  the  left  clavicle  by  a  rifle- 
ball,  which  traversed  his  lung  from  its  summit  to  its  base, 
and  was  found  lying  quite  superficially  in  the  left  lumbar  re- 
gion, from  which  position  it  was  removed.  The  dyspnoea, 
on  admission,  was  very  great,  and  the  haemoptysis  most 
profuse.  The  surface  was  cold  and  bedewed  with  cold  per- 
spiration. The  pulse  was  weak  and  tremulous,  and  the 
decubitis  was  on  the  wounded  side.  The  removal  of  the 
ball  was  followed  by  a  tremendous  gush  of  blood  from  the 
incision  made,  and  the  blood  continued  to  flow  in  such  quan- 
tity that  I  had  to  close  the  wound  to  prevent  immediate 
dissolution.  The  necessity  of  guarding  against  a  suddenly 
fatal  event  was  for  the  moment  paramount  to  the  indication 
of  freeing  the  embarrassed  lung  of  the  effused  blood  ;  and 
as  the  hemorrhage,  moreover,  appeared  to  be  active,  I  wished 
to  try  to  check  it  by  the  pressure  which  would  result  from 
the  blood  being  allowed  to  accumulate  in  the  thoracic  cav- 
ity. The  patient  was  twice  largely  bled,  and  he  had  acetate 
of  lead  and  opium  given  him.  These  measures  appeared  to 
afford  him  some  relief.  Next  day  he  had  rallied  considera- 
bly. His  pulse  was  better,  and  his  look  was  less  distressed. 
By  the  afternoon  of  that  day  the  dyspnoea  became  so  urgent 

favoriser  la  continuation  de  1'hsemorrbagie,  en  privant  la  plaie  du 
viiisseau  de  la  compression  salutaire  qu'exercent  sur  elle  le  sang 
rrtrnu  dans  la  poitrine  ainsi  que  les  caillots  qui  ont  pu  se  former.'' — 
S.VNSON,  Des  Hxmorrhagies  Tnt'tnin/i'/itc*,  p.  -<><>. 

19 


218  SURGERY    OF   THE    CRIMEAN    WAR. 

that  I  allowed  a  considerable  quantity  of  the  collected  blood 
to  escape.  This  gave  him  for  a  time  decided  relief.  The 
severe  exhaustion  which,  however,  soon  followed  this  step, 
and  the  return  of  the  dullness  on  percussion  to  its  former 
level,  seemed  to  intimate  a  renewal  of  the  hemorrhage ; 
hence  I  did  not  reopen  the  wound,  but  determined  to  ab- 
stain from  all  interference  till  the  bleeding  vessel  had  had 
time  to  close.  The  patient  was  so  completely  prostrated 
by  the  hemorrhage  which  had  evidently  taken  place  inter- 
nally that  I  could  not  have  recourse  to  any  further  depletive 
measures.  The  stethoscopic  examination  of  the  chest  dis- 
covered amphoric  breathing  over  the  upper  part  of  the  left 
lung,  while  over  the  whole  surface  of  the  right  chest  the  res- 
piration was  harsh  and  loud.  Dullness  existed  on  the  left 
side  from  the  base  of  the  lung  up  to  an  inch  and  a  quarter 
above  the  level  of  the  nipple.  There  was  suppression  of 
urine  for  thirty  hours  after  admission.  This  patient  died  on 
the  fifth  day,  without  any  change  in  his  symptoms  from 
those  noted  above.  The  left  side  of  the  thorax  was  found 
more  than  half  full  of  blood,  for  the  most  part  fluid.  The 
lung  was  half  solidified,  and  compressed  against  the  spine. 
Lymph  was  effused  to  a  limited  extent  on  its  surface.  The 
ball  had  traversed  the  lung  in  a  direction  from  above  down- 
ward and  backward.  Its  track  was  ragged  and  coated  with 
lymph.  The  three  upper  and  the  three  lower  ribs  were 
fractured.  The  patient's  back,  on  the  wounded  side,  was 
ecchymosed  before  death,  and  gave  him  much  pain.  This 
discoloration  bore  much  resemblance  to  that  ecchymosis 
described  by  Valentin — only  it  appeared  at  too  early  a  pe- 
riod, and  was  not  sufficiently  pronounced  to  accord  with  his 
description. 

I  am  not  in  a  position  to  determine  whether  the  retention 
of  the  blood  in  the  cavity  can  really  exert  so  great  a  press- 
ure on  the  wound  in  the  lung  as  to  arrest  the  bleeding ; 
but  such  was  the  opinion  of  Valentin,  Larrey,  Sanson,  and 
Dupuytren.  I  am  disposed  to  think  that,  in  such  cases  as 


WOUNDS   OF   THE   CHEST.  219 

the  foregoing,  it  would  be  better  practice  to  open  the  cavity 
freely  by  enlarging  the  wound,  so  as  to  allow  the  blood  to 
escape  freely,  and  thus  favor  the  contraction  of  the  lung  and 
the  closure  of  the  vessel ;  but  in  Hannihan's  case  such  a  step 
would  have  been  attended  with  much  danger,  from  his  great 
prostration. 

If  the  lancet  be  employed  in  such  cases,  it  is  a  matter  of 
the  greatest  nicety,  and  requires  the  utmost  discrimination 
and  judgment  to  abstract  exactly  the  quantity  of  blood  re- 
quisite for  producing  the  desired  effect  without  exhausting 
the  patient,  whose  system  has  been  already  so  much  drained 
by  the  internal  hemorrhage. 

Haemoptysis  does  not  always  occur  in  penetrating  wounds 
of  the  lungs,  and  dyspno3a  may  be  but  slightly  marked  at 
first.  The  following  case  was  an  example  of  this  :  M'Ken- 
nah,  private  17th  Regiment,  was  admitted  into  the  general 
hospital  July  27th.  When  in  one  of  the  advanced  trenches, 
a  Miiiic  ball  struck  him  obliquely  from  the  left  side  at  the 
middle  of  the  supra-spinous  fossa  of  the  left  scapula,  and 
lodged.  On  admission,  a  couple  of  hours  after  the  receipt 
of  the  wound,  slight  dyspnoea  was  the  only  observable  symp- 
tom, and  the  only  thing  the  patient  himself  complained  of. 
The  finger  passed  into  the  wound  showed  the  direction  of 
the  ball  to  have  been  toward  the  center  of  the  body,  but 
nothing  was  detected  except  some  roughness  along  the  pos- 
terior border  of  the  scapula.  In  the  evening  the  dyspnoea 
was  more  marked,  and  the  pulse  had  increased  in  frequency. 
The  decubitis  was  dorsal  throughout.  Emphysema  appeared 
over  the  surface  of  the  right  side  of  the  chest.  He  was 
largely  bled.  Next  day  the  above  symptoms  were  notably 
exaggerated,  and  dullness  was  added  on  percussion  on  the 
right  side,  posteriorly  and  laterally.  The  respiration  was 
puerile  over  the  anterior  superior  half  of  the  right,  and  over 
the  whole  of  the  left  lung.  The  bleeding  was  repeated,  digi- 
talis ordered,  and  nothing  allowed  in  the  way  of  food  but 
milk  and  cold  tea.  On  the  29th  the  dullness  had  invaded 


220  SURGERY    OF    THE   CRIMEAN    WAR. 

the  inferior  and  lateral  aspect  of  the  left  lung.  The  dysp- 
noea became  very  urgent,  and  was  not  relieved  by  any  treat- 
ment, depletory  or  otherwise ;  and  he  died  on  the  30th. 
Fluid  blood,  seemingly  the  product  of  oozing,  was  found  in 
both  pleural  cavities,  and  some  air  also  existed  on  the  right 
side.  Both  lungs  were  much  diminished  in  volume,  and 
floated  toward  the  upper  part  of  the  cavities.  The  ball 
had  passed  through  the  second  rib,  near  the  posterior  supe- 
rior angle  of  the  scapula,  and  perforated  the  apex  of  the  left 
lung  with  a  transit  of  one  and  a  half  inches.  It  had  there 
pierced  the  body  of  the  second  dorsal  vertebra,  fracturing 
and  partially  displacing  forward  its  anterior  half.  It  had 
then  entered  the  right  pleural  cavity,  traversed  the  apex  of 
the  right  lung,  struck  and  fractured  the  second  rib  on  the 
right  side  about  its  center,  and  finally  fell  spent  within  the 
pleural  cavity.  The  lungs  were  gorged  with  blood,  and 
their  outer  and  inferior  surfaces  were  coated  with  lymph. 
If  one  lung  only  had  been  wounded,  the  ball  and  the  effu- 
sion might  have  been  both  got  rid  of  by  operation  ;  but 
when  both  lungs  were  implicated,  such  interferences  would 
only  have  hastened  death. 

The  emphysema  which  was  present  in  this  case  was  prob- 
ably due  to  the  oblique  direction  of  the  wound.  It  was  a 
very  rare  occurrence  in  the  chest  wounds  which  I  had  an 
opportunity  of  witnessing. 

The  inflammation  which  follows  gunshot  wounds  of  the 
lungs  requires  the  same  treatment  as  that  which  is  given  to 
inflammation  from  any  other  cause.  When  only  a  small  part 
of  the  lung  has  been  penetrated,  then  the  pneumonia  may 
be  at  first  localized  ;  but  it  will  soon  spread  if  not  promptly 
subdued.  During  convalescence,  the  great  point  which  de- 
mands attention  is  to  guard  against  all  sources  of  relapse,  as 
inflammation  is  very  apt  to  be  re-established,  and  if  it  does 
reappear,  the  danger  of  its  giving  rise  to  purulent  effusion  is 
very  considerable.  Serous  effusions  often  cause  much  annoy- 
ance in  cases  of  wounds  of  the  chest.  According  to  Guthrie, 


WOUNDS  OF  THE  CHEST.  221 

such  effusions  take  place,  in  general,  from  the  third  to  the 
ninth  day,  and,  if  large,  imperatively  demand  early  evacua- 
tion. I  fear  this  rule  was  not  always  attended  to  during  the 
late  war.  It  is  difficult  to  know  what  is  the  Lest  period  of 
the  disease  to  put  it  in  practice. 

The  strictest  regimen  should  be  maintained  for  ten  days  or 
a  fortnight  after  the  infliction  of  a  gunshot  wound  of  the 
lung.  Any  irregularity  in  diet,  or  indulgence  in  ardent 
spirits  during  convalescence,  is  most  apt  to  cause  dangerous 
if  not  fatal  relapses  Not  a  few  were  lost  in  the  East  from 
such  carelessness.  Opium  is  of  much  use  in  allaying  the 
troublesome  cough,  which  often  continues  for  a  long  time. 
Hcnnen  speaks  of  "  a  sense  of  stricture  and  considerable 
pain  in  raising  the  body  to  an  erect  posture,  with  great 
anxiety  on  walking  up  an  ascent,"  as  being  frequent  conse- 
quences of  gunshot  wounds  of  the  chest;  and  at  another 
place  he  says,  "diseases  which,  although  we  cannot  call  them 
pulmonary  consumption,  agree  with  it  in  many  points,  par- 
ticularly in  cough,  emaciation;  debility,  and  hectic,  are  often 
the  consequences."  Veritable  phthisis  has,  however,  as  is 
well  known,  been  cured  by  the  rough  medication  of  a  gun- 
shot wound.  We  had  no  opportunity  of  watching  the 
remote  results  of  these  wounds,  as  the  patients  passed  from 
under  our  care  too  soon  for  their  development. 

Of  wounds  perforating  both  sides  of  the  chest,  I  met  with 
four  examples  only.  In  all  these  the  wound  was  inflicted 
by  grape,  and  all  died  in  a  very  short  time. 

Balls  are  well  known  occasionally  to  become  sacculated 
in  the  lung.  This  circumstance,  as  well  as  the  very  small 
amount  of  irritation  which  the  presence  of  such  a  body  may 
give  rise  to,  was  illustrated  in  the  following  case.  The  case 
was  first  related  to  me  by  my  friend  Deputy  Inspector- Gen- 
eral Gordon,  C.B.,  and  I  afterward  found  the  particulars  of 
the  early  symptoms  in  the  medicnl  reports  of  the  regiments 
serving  in  India:  A  soldier  of  the  53d,  serving  in  the  Pun- 
jab, received  a  ball  on  the  left  side  of  the  thyroid  cartilage, 

19* 


222  SURGERY    OF    THE    CRIMEAN    WAR. 

which  coursed  round  the  neck,  entered  the  apex  of  the  right 
lung,  traversed  it  to  near  its  base,  and  lodged.  Violent 
dyspnoea,  urgent  cough,  and  bloody  sputa  followed.  The 
patient,  from  the  fear  of  suffocation,  could  not  lie  down  for 
several  days.  These  symptoms  were  allayed  by  treatment, 
and  in  two  months  the  man  was  discharged,  feeling  no  incon- 
venience from  his  wound.  This  patient  died  six  months 
afterward  of  a  contagious  fever,  when  the  ball  was  found 
closely  sacculated  in  the  lower  lobe  of  the  lung,  at  the  apex 
of  which  a  small  puckering  was  seen,  but  no  trace  could  be 
discovered  of  the  ball's  track  from  the  apex  to  its  place  of 
sacculation.  The  lung  was  free  of  disease.  In  the  following 
case  the  position  of  the  ball  was  not  discovered :  A  soldier  of 
the  Buffs,  wounded  on  the  8th  September,  received  a  ball  on 
a  level  with  but  slightly  external  to  his  right  nipple.  Pro- 
fuse hemoptysis,  fainting,  great  dyspnoea,  oozing  of  blood 
from  the  wound,  and  the  escape  of  air  followed.  He  was 
largely  bled,  and  his  symptoms  thereby  relieved.  Ten  hours 
afterward,  a  return  of  the  difficulty  of  breathing  called 
for  further  depletion,  and  the  use  of  antimony.  Pneu- 
monia followed,  which  implicated  the  lower  half  of  the 
wounded  lung.  The  treatment  was  that  for  pneumonia 
generally.  The  wound  suppurated,  and  ultimately  closed. 
When  the  patient  left  the  hospital,  in  December,  the  lung 
acted  well  throughout,  except  for  a  short  distance  round  the 
wound,  where  it  was  dull  on  percussion,  and  seemingly  im- 
pervious to  air.  The  vocal  resonance  was  notably  increased 
over  the  upper  part  of  the  wounded  side  of  the  thorax. 

The  direction  taken  by  the  ball,  and  its  position  as  found 
after  death,  give  interest  to  the  following  case :  At  the  Alma 
a  soldier  was  struck  by  a  musket-ball,  on  the  outer  side  of 
the  left  shoulder.  His  arm  was  by  his  side  at  the  moment 
he  was  wounded.  It  was  observed  that  the  ball  had  passed 
through  the  head  of  the  humerus,  but  its  ultimate  position 
could  not  be  ascertained.  Nothing  was  done  for  the  arm. 
The  ball  was  supposed  to  have  made  a  clean  hole  through 


WOUNDS  OF  THE  CHEST.  223 

'  the  bone.  A  severe  attack  of  pleurisy  followed,  and  on  the 
subsidence  of  this,  pus  was  found  to  point  both  below  the 
clavicle  and  in  the  axilla  of  the  wounded  side.  Much  bone 
came  away.  Pus  flowed  copiously  by  the  openings  which 
were  made  in  the  axilla  and  below  the  clavicles.  The  pa- 
tient became  hectic,  and  died.  It  was  then  found  that  the 
ball,  having  passed  through  the  head  of  the  humerus  and  the 
glenoid  cavity,  had  entered  the  chest  between  two  of  the 
ribs,  and  having  run  forward  within  the  cavity,  and  between 
the  walls  and  the  pleura,  had  lodged  in  the  anterior  medias- 
tinum, where  it  was  found  coated  with  lymph.  The  chest 
symptoms,  the  surgeon  in  charge  informed  me,  had  been  very 
slight,  and  the  presence  of  the  ball  had  given  rise  to  no  un- 
easiness. If  the  joint,  which  was  the  main  source  of  irrita- 
tion and  hectic,  hud  been  excised  early,  a  more  favorable 
result  might  have  followed. 

The  four  following  cases  are  further  illustrations  of  most 
severe  gunshot  wounds  implicating  the  lung: — 

At  the  Alma  a  soldier  was  struck  by  a  ball  near  the  cen- 
ter of  the  left  axilla.  The  bullet  escaped  on  the  same  level 
as  that  at  which  it  had  entered,  and  within  an  inch  and  a 
half  of  the  spine.  Profuse  hemorrhage  by  the  wound  and 
by  the  mouth  followed  immediately  and  caused  the  patient 
to  faint.  He  was  bled  at  night,  as  well  as  next  morning,  to 
relieve  the  dyspnoea,  which  was  urgent.  A  severe  attack  of 
pneumonia  followed,  which,  though  subdued,  recurred  on 
two  subsequent  occasions.  By  December  the  lung  had  re- 
covered, except  at  its  base,  where  it  was  impervious  to  air. 
The  respiration  at  the  summit  was  exaggerated.  There  was 
in  the  hospital  at  the  same  time  another  man,  whose  wound 
and  its  results  were  exactly  similar,  only  that  the  ball  had 
entered  by  the  right  axilla  in  place  of  the  left,  and  had 
escaped  a  very  little  lower  than  in  the  last  case.  In  this 
case  the  liver  escaped  injury. 

A  sergeant  was  struck  at  the  Alma  by  a  musket-ball,  on 
the  right  side,  between  the  sixth  and  seventh  ribs,  close  to 


224  SURGERY   OF   THE   CRIMEAN    WAR. 

their  angles.  The  ball  traversed  the  lung,  and  escaped  close 
above  the  inner  angle  of  the  clavicle  of  the  same  side.  The 
man  said  that,  on  the  receipt  of  the  wound,  his  mouth  filled 
with  blood,  and  that  he  fell  down  and  thought  he  was  killed. 
Profuse  ha3moptysis  continued  for  some  days  after  his  admis- 
sion into  hospital.  He  was  largely  bled  a  few  hours  after 
being  wounded,  and  also  on  the  two  succeeding  days,  when 
the  difficulty  of  breathing,  from  which  he  suffered,  became 
severe.  Tartar  emetic  was  given  him  and  he  was  kept  ex- 
ceedingly low  for  several  days.  Both  wounds  suppurated 
freely.  Amphoric  breathing  was  very  evident  over  the 
upper  part  of  the  wounded  lung ;  but  there  was  no  marked 
change  on  percussion  anywhere  for  a  week  after  the  receipt 
of  the  injury.  He  complained  of  severe  pain  in  the  injured 
lung  during  the  whole  period  he  continued  in  hospital. 
Three  weeks  after  being  wounded,  there  was  a  deficiency  in 
the  respiratory  murmur  all  over  the  right  side,  which  defi- 
ciency was  balanced  by  an  increase  on  the  left.  Broncho- 
phony  was  marked  at  the  upper  part  of  the  right  side. 
There  was  dullness  now  on  percussion  all  over  the  right 
lung,  but  chiefly  at  its  upper  part.  The  expectoration  was 
profuse  and  purulent.  Cough  severe  and  painful.  Pulse 
high  and  irritable.  His  gums  were  sore  with  mercury,  and 
blisters  had  been  repeatedly  applied  to  the  surface  of  his 
chest.  He  gradually  recovered  under  the  influence  of  a 
generous  diet;  and  when  he  went  to  England,  about  four 
months  after  being  wounded,  both  wounds  were  closed,  the 
anterior  having  cicatrized  first.  At  that  period  the  right 
side  of  his  chest  was  somewhat  contracted  and  flattened. 
The  respiratory  murmur  was  fair  over  the  upper  two-thirds 
of  the  right  lung,  but  faint  toward  the  base.  Percussion 
gave  a  normal  note,  except  at  a  small  point  just  at  the  apex 
and  at  the  base,  where  the  sound  was  dull.  A  good  deal 
of  bone  had  been  discharged  by  the  wounds  during  conva- 
lescence. 

A  French  soldier  had  a  Minie  ball  driven  through  his 


WOUNDS   OF   THE   CHEST.  225 

right  chest  at  Inkerman.  It  entered  an  inch  below  the 
nipple,  between  two  of  the  ribs,  and  escaped  behind,  exactly 
opposite  the  place  of  its  entrance,  within  two  inches  of  the 
spine,  fracturing  one  rib  and  chipping  another.  Severe 
hemoptysis  and  bleeding  from  the  wound  followed.  He 
was  bled  frequently  and  kept  very  low  afterward.  Most 
violent  inflammation  set  in,  and  effusion  took  place  into  the 
pleural  cavity.  The  fluid  was  not  evacuated ;  but  while  it 
was  being  absorbed,  the  wound  of  entrance  having  closed, 
a  most  violent  and  prolonged  attack  of  trismus  seized  him, 
which,  for  a  couple  of  days,  threatened  to  cause  death,  but 
which  ultimately  yielded  to  large  doses  of  opium,  without 
the  spasms  becoming  general  over  the  body.  This  patient 
perfectly  recovered  and  was  sent  to  France. 

A  soldier  of  the  Guards  was  struck  at  Inkerman  by  a  rifle- 
ball,  which  was  fired  at  a  short  distance  behind  him  by  one 
of  our  own  men.  It  entered  below  the  angle  of  the  right 
scapula,  and  escaped  between  the  fourth  and  fifth  ribs,  chip- 
ping the  upper  edge  of  the  latter.  The  haemoptysis  was 
very  profuse,  and  much  blood  escaped  by  the  wounds.  He 
sank  down  exhausted  almost  immediately  on  receipt  of  the 
wound,  and  lost  consciousness  shortly  afterward.  He  lay 
a  considerable  time,  he  could  not  say  how  long,  before  he 
recovered.  When  he  was  received  into  hospital,  blood  con- 
tinued to  ooze  from  his  wounds,  he  spat  constantly,  and  his 
breathing  was  greatly  impeded.  He  was  bled  twice  during 
his  stay  in  the  Crimea,  and  when  I  saw  him  a  month  after- 
ward, he  had  in  a  great  measure  recovered.  The  exit  wound 
had  closed,  but  that  of  entrance  had  taken  on  a  phagedenic 
action  for  some  days  and  was  not  yet  healed.  The  lung 
acted  well;  he  could  lie  on  either  side;  and,  to  all  appear- 
ance, he  was  in  a  fair  way  to  a  complete  recovery. 

When  no  adhesions  are  formed,  by  which  the  ball  or  other 
foreign  bodies  driven  into  the  thorax  are  arrested,  they  gen- 
erally are  found  lying  on  the  diaphragm,  in  the  angle  formed 
by  it  and  the  costal  walls,  and  close  to  the  vertebral  column. 


226  SURGERY    OF    THE   CRIMEAN    WAR. 

The  track  of  a  ball  through  a  lung  has  been  occasionally 
found  to  become  fistulous,  becoming  lined  by  a  membrane, 
and  containing  curdy  pus.  The  pulmonary  tissue  around 
these  tracks  becomes  indurated,  and  they  may  or  may  not 
have  an  orifice  to  the  exterior  of  the  chest.  A  circum- 
scribed abscess  may  exist  between  the  ribs  and  the  lung,  or 
be  in  the  lung  substance  itself,  and  communicate  with  this 
track.  The  perfect  manner  in  which  these  collections  and 
the  track  connected  with  them  are  closed  off  from  the  lung, 
and  the  evil  which  may  arise  from  the  presence  of  this  pus, 
make  it  a  question,  which  the  facts  before  me  do  not  enable 
me  to  discuss,  whether  or  not  it  would  be  advisable  to  eva- 
cuate it  by  operation,  seeing  that  our  modern  means  of  diag- 
nosis would  permit  of  its  detection.  This  evacuation  could 
be  accomplished  by  such  a  puncture  through  the  parietes  as 
would  insure  the  closure  of  the  wound  as  soon  as  the  object 
was  effected. 


CHAPTER  IX. 

GUNSHOT  WOUNDS  OF  THE  ABDOMEN  AND  BLADDER. 

The  returns  of  the  war,  after  April  1st,  18.r>5,  show  flesh  contusions  and 
wounds  (simple  and  severe)  of  the  abdomen,  among  the  privates,  as 
having  occurred  101  times,  with  a  fatal  issue  in  17  cases.  There  were 
38  penetrating  wounds  with  lesion  of  viscera,  and  36  deaths  in  conso- 
(|iicnco:  while  65  times  the  abdomen  was  perforated,  and  60  deaths 
resulted.'*  Four  cases  of  rupture  of  viscera  without  wound  were  fatal. 

The  abdominal  cavity,  from  the  want  of  a  bony  protection 
in  front,  as  well  as  from  its  large  surface,  is  very  liable  to 
severe  injury  in  battle,  and  there  is  no  cavity  in  the  body 
the  injuries  of  which  are  more  serious  or  more  often  fatal. 
The  ribs  protect  the  contents  of  the  thorax  from  contusions, 
and  wounds  from  pieces  of  shell  often  fail  to  injure  either 
the  lungs  or  heart;  but  when  a  projectile  impinges  with  any 
force  on  the  abdomen,  the  effects  are  seldom  limited  to  its 
walls. 

*  M.  Legouest  mentions  3  cases  of  penetrating  wounds  of  the  ab- 
domen in  the  Dolnia  Batch!  hospital,  all  of  which  died.  Alcock 
reports  19,  only  1  of  which  recovered.  Meniere  mentions  14  in 
which  the  ball  penetrated,  2  of  them  being  through  the  side,  and  all 
died;  while  of  7  others,  in  which  the  ball  passed  through  the  side 
only,  recovery  followed.  In  the  Indian  wars  I  find  the  record  of  38 
penetrating  or  perforating  wounds  of  the  abdomen,  of  whom  32  died 
and  6  recovered.  Colles  states  that  in  the  sieges  of  Moultan  "  not 
one  case  recovered  in  which  the  abdomen  was  fairly  shot  into  and 
the  small  intestine  wounded."  S<5dillot  tells  us  that  in  the  expedi- 
tion against  Const antine  they  lost  all  those  whose  abdomens  were 
penetrated  by  gunshot. 

(227) 


228  SURGERY    OF    THE    CRIMEAN   WAR. 

It  is  often  difficult  to  tell  what  influence  a  certain  wound 
will  produce  when  it  affects  the  abdomen.  At  times  an 
accident  apparently  severe  is  followed  by  trivial  conse- 
quences, while  the  most  disastrous  results  may  arise  from  an 
injury  which  shows  little  external  indication  of  its  severity. 

Contusions  by  round  shot  are  among  the  most  dangerous 
injuries  to  which  the  abdomen  is  exposed.  The  hollow  or 
the  solid  viscera,  as  is  well  known,  may  be  thus  ruptured, 
and  rapid  death  follow,  without  much  external  sign  of  so 
severe  an  accident.  Every  campaign  furnishes  examples  of 
this.  A  contusion  may,  however,  arise  from  a  less  ponder- 
ous missile  than  a  round  shot,  and  the  injury  be  not  so 
serious.  The  state  of  tension  of  the  wall  of  the  abdomen 
at  the  time  of  the  accident  appears  to  exercise  no  little 
influence  on  the  effects  produced.  When  a  man  is  lying  on 
the  ground,  and  the  muscles  are  completely  relaxed,  then  the 
injury  inflicted  on  the  contained  viscera  may  be  very  severe ; 
but  if  the  muscles  are  in  action  and  tense,  then  the  force  of 
the  blow  will  be  somewhat  mitigated.  At  least  such  is  the 
only  manner  in  which  I  could  explain  several  anomalous 
cases  that  fell  under  my  notice. 

Vomiting  and  pain  in  the  abdomen  are  the  signs  of  injury 
to  which  contusions  of  the  cavity  generally  give  rise;  and 
if  no  serious  damage  has  been  done,  all  the  treatment  those 
cases  require  is  such  as  will  ward  off  peritoneal  inflammation, 
which  may  steal  on  very  insidiously.  If  any  internal  rupture 
has  taken  place,  we  can  do  little  to  prevent  a  fatal  issue. 

Shell  wounds  of  the  walls  of  the  abdomen  are  very  com- 
monly followed  by  extensive  sloughing,  and  the  danger  of 
the  morbid  action  laying  bare  the  intestines,  or  at  any  rate 
favoring  their  subsequent  protrusion,  is  considerable.  In 
one  case  which  fell  under  my  observation,  nearly  the  whole 
of  the  anterior  wall  of  the  abdomen  was  destroyed  by  the 
sloughing  caused  by  a  shell  wound. 

Guthrie  seems  to  think  that  a  greater  amount  of  destruc- 
tion occurs  in  the  abdominal  walls  than  can  be  accounted 


WOUNDS   OF   THE   ABDOMEN   AND    BLADDER.  229 

for  by  their  mere  injury,  this  loss  being  probably  caused  by 
their  absorption. 

Balls  often  traverse  the  abdominal  walls  for  a  considerable 
distance  without  entering  the  cavity,  and  they  do  this  at 
times  by  so  long  a  transit  as  to  describe  half  the  circuit  of 
the  body.  Of  this  very  many  cases  occurred  in  the  Crimea. 
The  strong  aponeurosis  which  protects  the  front  of  the 
abdomen  exercises  a  great  influence  in  deflecting  the  ball 
when  it  has  struck  at  all  obliquely.  The  track  which  is 
thus  made  requires  careful  management  during  cure  to  get 
it  to  close.  If  it  be  long,  it  is  good  practice  to  make  a 
counter-opening  at  its  center,  in  order  to  prevent  the  lodg- 
ment of  pieces  of  cloth  or  pus  in  its  interior.  This  can, 
however,  be  necessary  only  when,  neither  by  syringing  nor 
by  the  introduction  of  an  elastic  bougie,  we  can  get  quit  of 
them. 

Abscesses  among  the  muscles  are  not  uncommon,  although 
very  disagreeable  complications  of  gunshot  injuries,  and 
especially  of  contusions  of  the  abdominal  walls.  Severe 
pain,  vomiting,  and  other  symptoms  which  may  be  mistaken 
for  those  of  internal  inflammation,  may  be  thus  set  up. 

If  the  amount  of  inflammation  caused  by  contusion  or 
other  injury  of  the  abdominal  wall  be  limited,  then  adhesion 
will  take  place  between  the  parietes  and  the  omentum  or 
viscera,  and  will  afford  a  great  safeguard  against  the  effusion 
of  blood  or  other  matters  into  the  cavity.  If,  however,  the 
parietes  in  part  slough,  so  that  the  gut  is  laid  bare  or 
opened,  the  injury  is  one  of  great  gravity. 

It  is  sometimes  very  difficult  to  say  whether  a  ball  has 
perforated  the  abdomen  or  not.  The  relative  position,  and 
even  the  peculiar  characters  of  the  two  orifices,  will  not 
guarantee  a  decided  opinion.  Far  less  can  we  say,  from 
the  apparent  direction  of  the  wound,  that  any  of  the  viscera 
have  been  injured.  It  is  neither  allowable  nor  desirable 
that  we  should  make  such  a  search  as  will  determine  the 
question;  for  if  the  ball  be  not  easily  found,  we  never 

20 


230  SURGERY   OF   THE   CRIMEAN   WAR. 

"amuse  ourselves,"  as  Le  Dran  expresses  it,  "by  seeking 
for  it,"  and  the  treatment  ought  to  be  such  as  will  provide 
for  all  contingencies.  In  the  following  case,  the  ball  ap- 
peared not  only  to  have  perforated  both  the  abdomen  and 
the  chest,  but  also  the  diaphragm ;  yet  probably  it  ran  merely 
under  the  integuments,  possibly  traversing  the  diaphragm 
close  to  its  anterior  border,  and  wounding  none  of  the  ab- 
dominal or  thoracic  viscera :  A  ball  struck  a  French  soldier 
just  above  the  crest  of  the  ileura,  and  about  four  inches  from 
the  spine.  It  escaped  close  below  the  inner  end  of  the 
clavicle  on  the  same  side.  At  the  time  he  was  struck  this 
man  was  on  his  knees,  as  he  was  in  the  act  of  rising  from 
the  ground  on  which  he  had  been  lying.  He  had  hiccough 
and  considerable  prostration  for  three  days,  and  also  an 
attack  of  pleurisy,  all  of  which  he  had  recovered  from  a 
fortnight  after  injury,  when  I  first  saw  him. 

The  fatality  of  penetrating  wounds  of  the  belly  will 
depend  much  on  the  point  of  their  infliction.  Balls  enter- 
ing the  liver,  kidneys,  or  spleen  are  well  known  to  be 
usually  mortal,  although  exceptional  cases  are  not  rare.* 
Wounds  of  the  great  gut  are  also  always  recognized  as 
much  less  formidable  than  those  which  implicate  the  small. 
Thomson  saw  only  two  cases  of  wounds  of  the  small  gut, 
after  Waterloo,  in  the  way  of  recovery ;  but  Larrey  reports 
several.  Gunshot  wounds  of  the  stomach  are  also  exceed- 
ingly fatal.  Baudens  records^  a  remarkable  case  of  recovery, 
although  complicated  with  severe  head  injuries.  The  syn- 
cope which  followed  the  severe  hemorrhage  in  this  case 
lasted  for  ten  hours,  and  doubtless  assisted,  along  with  the 
empty  state  of  the  stomach  at  the  moment  of  injury,  in  pre- 
venting a  fatal  issue. 

The  extraordinary  manner  in  which  not  only  balls,  but 

*  See  especially  the  most  remarkable  case  related  by  Hennen,  at 
page  455  of  the  first  edition  of  his  admirable  "Observations." 
f  Observations  IV.,  p.  12,  of  his  "Clinique." 


WOUNDS   OF    THE   ABDOMEN   AND   BLADDER.  231 

also  swords  and  rararods,  may  traverse  the  abdominal  cavity, 
and  yet  not  wound  any  viscus,  has  been  often  dwelt  upon  by 
military  surgeons.  The  escape  of  the  viscera  in  the  follow- 
ing case,  which  occurred  in  India,  was  most  remarkable :  A 
soldier  of  the  28th  Regiment,  endeavoring  to  commit  suicide, 
leant  over  his  musket,  and  drew  the  trigger  with  his  toe. 
The  ball  passed  into  the  abdomen,  on  a  level  but  a  little  to 
the  left  of  the  umbilicus,  and  escaped  through  the  center  of 
the  crest  of  the  left  ileum  behind.  He  died  in  a  month. 
The  intestines  were  found  matted  together,  and  large  por- 
tions of  them  were  gangrenous,  but  no  perforation  of  the 
gut  could  be  discovered.  The  surgeon,  Dr.  Young,  adds  in 
his  report:  "This  examination,  however,  in  some  particulars 
unsatisfactory,  has  at  least  established  the  fact  that  the  in- 
testines were  not  perforated  by  the  ball ;  but  how  they 
escaped,  defies  any  conjecture  I  can  form  on  the  subject." 
In  another  case  which  occurred  at  Meanee,  the  ball  was 
ascertained  to  have  gone  fairly  through  the  abdomen,  yet 
not  to  have  injured  any  of  the  viscera.  It  is  impossible, 
however,  to  be  certain  of  such  a  circumstance,  unless  an 
after-death  examination  verify  a  supposition  we  are  too  apt 
to  form. 

The  just  and  perfect  support  afforded  by  the  abdominal 
viscera  to  one  another,  and  the  manner  in  which  they  fill 
their  containing  cavity,  supply  a  safeguard  against  effusion 
after  wounds,  which  has  ever  been  the  astonishment  and  ad- 
miration of  observers.  The  smaller  and  less  torn  the  wound 
in  the  gut  is,  the  more  likely  is  this  favorable  result  to  occur. 
Littre's  celebrated  case  of  the  madman  has  ever  served  as 
the  type  of  such  wonderful  acts  of  "conservative  effort." 
The  pressure,  too,  favors  that  adhesion  between  the  viscera, 
which  is  so  potent  a  preservative  against  evil. 

The  following  case,  reported  by  Dr.  Taylor  when  surgeon 
of  the  80th,  affords  an  example  of  a  gunshot  wound  injuring 
the  smaller  gut,  while  at  the  same  time  it  shows  the  effects 
of  such  a  wound,  and  also  the  state  of  the  parts  a  considerable 


232  SURGERY   OP   THE   CRIMEAN    WAR. 

period  after  the  infliction  of  the  injury.     It  is  taken  from 
the  Records  of  the  Medical  Department : — 

Private  Paul  Massy  was  shot  through  the  abdomen  at 
Ferozeshah.  Very  slight  symptoms  followed,  so  that  it  was 
supposed  the  ball  had  coursed  round  the  cavity,  and  had  not 
penetrated.  He  mentioned  having  passed  some  blood  in  his 
stools  after  receiving  his  wound.  The  ball  had  escaped  near 
the  spine,  having  entered  in  front.  He  recovered  slowly 
but  perfectly,  except  that  he  continued  subject  to  bowel 
complaint,  and  finally  died  of  spasmodic  cholera,  a  consider- 
able time  (exact  period  not  specified)  after  being  wounded. 
For  a  year  before  death  he  was  almost  constantly  under 
treatment  for  dysentery.  When  examined  after  death,  the 
following  was  the  condition  found.  I  give  it  in  Dr.  Taylor's 
own  words:  "  Cicatrix  of  a  gunshot  wound  in  the  left  linea 
semiluuaris,  about  four  inches  above  the  crest  of  ileum ;  and 
on  the  same  plane  posteriorly,  another  cicatrix  an  inch  to 
the  left  of  the  spine.  Omentum  firmly  adherent  to  the  in- 
ternal surface  of  anterior  cicatrix,  and  gathered  into  a  fold 
or  knot  at  that  part.  The  intestines  were  neither  there  nor 
elsewhere  morbidly  adherent;  but  the  fold  of  intestine  im- 
mediately opposite  to  the  cicatrix  presented  a  line  of  con- 
traction, as  if  a  ligature  had  been  passed  tightly  round  the 
gut.  The  fold  of  intestine  immediately  above  presented  the 
same  appearance,  and  on  the  first  fold,  four  inches  from  the 
first-noticed  contraction,  and  in  a  line  below  the  umbilicus, 
was  another  similar  appearance.  These  three  contracted 
places  were  of  a  darker  hue,  and  more  vascular  than  other 
portions  of  the  small  intestine  ;  having,  however,  throughout 
an  arborescent  vascularity,  and  being  in  the  sodden  state 
constantly  seen  in  sudden  cases  of  spasmodic  cholera.  The 
mucous  membrane  of  the  small  intestine  was  generally  of  a 
pale-pink  color.  No  ulceration  of  the  large  gut.  Upper 
part  of  the  colon  attenuated,  and  contracted  in  situ.  Rec- 
tum thickened."* 

*  The  preparations  made  of  the  above  parts  were  sent  to  Fort 
Pitt. 


WOUNDS   OF   THE   ABDOMEN    AND   BLADDER.  233 

When  a  ball  merely  enters  the  gut,  it  may  be  thrown  out 
by  stool.  Such  a  case  occurred  in  the  19th  Regiment  in 
the  Crimea,  and  is  reported  by  the  surgeon  in  the  Lancet, 
vol.  i.,  1855. 

If  a  vascular  viscus  be  wounded,  or  a  large  blood-vessel 
opened,  then  hemorrhage  may  take  place  within  the  abdomen 
to  a  very  serious  and  fatal  extent.  The  mutual  pressure  of 
the  viscera  does  much  to  prevent  bleeding  from  the  former 
source,  and  the  lax  attachment  of  the  arteries  in  general 
enables  them  to  escape.  If  blood  be  poured  out  suddenly 
and  in  quantity,  it  will  partly  escape  by  the  wound,  and 
partly  collect  at  the  most  dependent  part  of  the  abdomen, 
or  in  the  pelvis.  Bautiens  mentions  as  a  certain  sign  of  a 
quantity  of  blood  being  collected  in  the  pelvis,  the  incessant 
and  insupportable  desire  to  micturate  caused  by  the  pressure 
on  the  bladder,  and  which  is  set  up,  although  there  is  no 
urine  in  the  viscus.  Besides  the  immediate  danger  which 
proceeds  from  the  loss  of  blood,  such  effusions,  if  in  quantity, 
fail  to  become  absorbed,  decompose,  set  up  inflammation,  and 
cause  death.  The  quantity  must  be  small  which  will  insure 
its  absorption.  It  is  therefore  a  matter  of  some  importance 
to  evacuate  such  accumulations  by  reopening  the  wound, 
rather  than  to  attempt  its  removal  by  operation  afterward. 

The  symptoms  of  penetrating  wounds  of  the  abdomen  are 
those  which  belong  to  the  accident  proper,  and  those  which 
result  from  its  consequences.  The  collapse  is  generally  very 
severe,  and  this  is  the  case,  too,  in  many  instances  in  which 
the  injury  appears  at  first  very  superficial  and  trivial.  While, 
in  general,  this  shock  and  alarm  are  indicative  of  deep  and 
serious  lesion,  they  are  aften  excited  by  no  apparently  ade- 
quate cause.  If  some  hemorrhage,  or  the  effusion  of  any 
of  the  secretions,  as  bile,  or  the  contents  of  any  of  the  hollow 
viscera  follow  the  injury,  then  the  collapse  will  not  only  be 
severe,  but  will  continue. 

The  subsequent  symptoms  of  these  wounds  will  partake  of 
two  characters- — those  common  to  all  inflammations  ot  the 

20* 


234  SURGERY   OF   THE    CRIMEAN    WAR. 

abdomen,  and  those  arising  from  the  inflammation  of  the 
particular  organ  injured.  The  inflammation  which  is  so 
certain  to  occur  in  the  peritoneum  requires  very  careful 
watching,  as  it  often  sets  in  very  slowly  and  deceptively. 
"  The  consciousness  of  imperfection  induced  in  the  cavity," 
of  which  Hunter  speaks,  makes  it  peculiarly  apt  to  take  on 
an  inflammatory  action. 

The  position  and  direction  of  the  wound,  and  the  concur- 
rent symptoms  referable  to  the  lesion  of  special  organs,  will 
lead  us  to  surmise  the  injury  of  this  or  that  viscus.  The 
persistent  vomiting,  the  ejection  of  blood  by  the  mouth  or  by 
stool,  or  with  the  urine,  the  escape  of  special  secretions,  as 
bile,  by  the  wound,  the  peculiar  pain  or  sensation  experienced 
by  the  patient,  will  be  our  chief  indications  in  determining 
the  part  hurt.* 

The  treatment  of  simple,  non-penetrating  wounds  requires 
but  little  notice — the  prevention  or  subdual  of  inflammation, 
and  the  favoring  by  position  of  that  conservative  adhesion 
between  the  viscera  and  the  parietes  which  is  desirable  if 
sloughing  should  set  in,  so  as  to  endanger  the  opening  of 
the  cavity. 

The  management  of  penetrating  wounds  is  not  much  more 
difficult,  but  the  results  are  very  much  less  satisfactory.  When 
the  penetration  has  been  occasioned  by  a  ball,  it  is  not  often 
that  we  have  an  opportunity  of  verifying  the  fact  of  visceral 
lesion.  No  attempt  should  be  made  to  follow  the  ball.  The 

*  Hunter  says  of  the  blood  passed  by  stool:  "If  it  is  from  a  high 
part  of  an  intestine,  it  will  be  mixed  with  faeces  and  of  a  dark  color; 
if  low  as  the  colon,  the  blood  will  be  less  mixed  and  give  the  tinge  of 
blood;"  and  of  the  character  of  the  feeling,  he  adds:  "The  pain  or 
sensation  will  be  more  or  less  acute  according  to  the  intestine 
wounded;  more  of  the  sickly  pain  the  higher  the  intestine,  and  more 
of  the  acute  the  lower."  It  would  be  a  matter  of  some  moment  that 
we  could  rely  on  this  sign.  We  can  seldom,  however,  distinguish  the 
character  of  the  pain  from  the  patient's  statement,  and  it  does  not 
always  aiford  us  a  true  guide  when  it  is  recognized. 


WOUNDS   OF   THE   ABDOMEN    AND    BLADDER.  235 

wound  should  be  lightly  covered,  the  patient  placed  in  such  a 
position  as  will  relax  the  abdominal  walls,  fomentations  ap- 
plied by  means  of  the  lightest  possible  material,  opium  freely 
given  by  the  mouth  ;  and,  if  inflammation  set  in,  then  leeches 
and  even  general  blood-letting  may  be  had  recourse  to. 

"All  wounds  that  enter  the  belly,"  says  Hunter,  "which 
have  injured  some  viscus,  are  to  be  treated  according  to  the 
nature  of  the  wounded  part,  with  its  complications,  which 
will  be  many  ;  because  the  belly  contains  more  parts  of  very 
dissimilar  uses  than  any  other  cavity  of  the  body,  each  of 
which  will  produce  symptoms  peculiar  to  itself  and  the  na- 
ture of  the  wound."  "  It  cannot  be  too  frequently  re- 
peated," says  Dr.  John  Thomson,  "that  copious  blood- 
letting, and  the  use  of  the  antiphlogistic  regimen  in  all  its 
parts,  are  the  best  auxiliaries  which  the  surgeon  can  employ 
in  the  case  of  all  injuries  of  the  viscera,  contained  within 
the  cavity  of  the  abdomen."  With  us  in  the  East  the  state 
of  our  patients  necessitated  a  much  more  cautious  use  of  the 
lancet  in  these  and  in  all  other  injuries,  than  is  common. 
Opium,  however,  was  the  chief  reliance  in  these  lesions,  as 
it  allayed  that  pain  and  anxiety  which  might,  without  it, 
have  been  interpreted  into  a  call  for  depletion.  The  most 
extreme  abstinence  from  food  is  certainly  one  of  the  most 
important  points  in  treating  penetrating  wounds  of  the  ab- 
domen. Purgatives  by  the  mouth  will 'do  harm  only,  but 
clysters,  especially  of  warm  oil,  are  particularly  useful  and 
agreeable  to  the  patient. 

Few  cases  occur  in  military  practice  which  demand  the 
use  of  the  suture  to  the  intestine.  Such  cases  are  generally 
fatal.  To  those  in  which  its  employment  is  not  distinctly 
indicated,  Hunter's  remark  particularly  applies  :  "  I  should 
suppose  the  very  best  practice  would  be  to  be  quiet,  and  do 
nothing  except  bleeding,  which,  in  cases  of  wounded  in- 
testine, is  seldom  necessary. " 

Early  protrusion  of  the  gut  is  rare,  unless  the  wound  has 
been  occasioned  by  a  large  ball,  as  a  grape-shot.  Its  care- 


236  SURGERY   OF   THE   CRIMEAN    WAR. 

fill  return  isr  of  course,  the  rule  of  practice  when  it  does 
occur.  Guthrie  has  shown  the  propriety  of  leaving  pro- 
truded omentum  to  act  as  a  plug  in  the  wound. 

It  is  in  wounds  of  the  abdomen  that  the  treatment  by 
"  debridement  "  retains  its  last  footing.  The  fear  of  stran- 
gulation by  the  strong  fasciae,  or  between  the  muscles,  is  as- 
signed as  the  claim  it  has  to  adoption  in  these  wounds.  But 
experience,  while  it  has  overthrown  this  cause  of  anxiety, 
has  shown  that  a  positive  evil  is  occasioned  by  the  practice, 
in  so  far  as  that  the  abdominal  walls  are  weakened  by  it, 
and  hernia  the  more  apt  to  ensue.  This  step  then  is 
abandoned  here,  as  in  all  other  regions,  unless  an  absolute 
necessity  arise  for  its  adoption.  In  the  case  of  narrow 
wounds  through  the  deep  muscles  of  the  back,  by  which 
fa3ces  ooze,  but  cannot  get  a  free  escape,  in  similar  wounds 
penetrating  the  bladder,  or  in  cases  in  which  a  large  amount 
of  blood  has  been  effused  into  the  abdomen,  it  may  be  neces- 
sary to  enlarge  the  wound,  in  order  to  prevent  ulterior  con- 
sequences of  more  gravity  than  those  which  can  follow  from 
the  step  itself. 

If  a  false  anus  result  from  a  penetrating  wound  by  gun- 
shot, the  cure  will  in  most  cases  take  place  in  time  spon- 
taneously. Of  this  I  observed,  with  much  interest,  two 
cases  at  Constantinople,  both  of  which  very  quickly  got  well. 
A  plastic  operation  at  a  late  date  will  probably  supply  what 
is  deficient  in  the  effort  of  nature. 

Where  the  destruction  of  soft  parts  has  been  considerable, 
the  danger  of  ventral  protrusion  will  require  attention  during 
.  after-life,  and  no  little  trouble  is  often  caused  by  the  irregular 
action  of  the  viscera,  by  pains  which  either  wander  through- 
out the  cavity  or  localize  themselves  at  the  point  wounded. 
These  uneasy  sensations  are  increased  by  any  distention, 
such  as  that  which  follows  a  full  meal,  and  they  continue  to 
distress  the  patient  during  digestion.  Dupuytren  dwells  on 
the  effects  of  that  chronic  inflammation  which  may  be  set 
up  by  a  contusion  of  the  gut,  and  which,  he  says,  may  bring 


WOUNDS   OF   THE   ABDOMEN   AND   BLADDER.  237 

about  a  stricture  of  the  intestinal  canal,  or  its  cancerous 
degeneration. 

I  had  fewer  cases  of  penetrating  wounds  of  the  abdomen 
under  ray  notice  in  the  East,  than  of  almost  any  other  seri- 
ous injury.  The  following  are  given  as  among  the  most 
interesting  of  those  of  which  I  have  retained  notes  : — 

Cousins,  a  private  in  the  77th  foot,  aged  18,  was  admitted 
into  the  general  hospital,  under  Mr.  Rooke,  on  the  8th  of 
June.  When  standing  in  one  of  the  advanced  trenches, 
sideways  to  the  enemy,  his  right  arm  being  stretched  out  in 
front  of  his  hip,  he  was  struck  by  a  round  shot  or  large 
piece  of  shell,  which  completely  smashed  his  right  forearm, 
and  fractured  the  ileum  of  the  same  side,  causing  at  the 
same  time  a  lacerated  wound  of  the  right  iliac  region  about 
5  inches  long  by  3  broad.  The  wall  of  the  abdomen,  in- 
cluding the  peritoneum,  was  destroyed  to  the  extent  men- 
tioned, and  a  coil  of  intestine  was  laid  bare.  No  protrusion 
took  place,  nor  was  the  gut  seemingly  injured.  Besides 
the  fracture  and  destruction  of  the  crest  of  the  ileum,  the 
anterior  superior  spinous  process  of  that  bone  was  quite 
detached,  and  the  great  trochauter  was  also  fractured.  The 
leg  on  the  wounded  side  was  shortened  very  considerably, 
and  the  foot  was  everted.  As,  from  the  extent  of  the 
injury  sustained  and  the  collapse  present,  it  was  supposed 
that  this  patient  would  die  shortly  after  admission,  nothing 
was  done  for  him  beyond  simply  dressing  his  wounds  and 
giving  him  stimulants  in  small  quantities.  Next  day,  how- 
ever, he  had  so  far  rallied  that  some  hopes  were  entertained 
for  him,  but  it  was  not  till  the  second  day  that  he  had  suf- 
ficiently improved  to  allow  of  his  arm  being  amputated. 
This  was  of  course  done  under  chloroform,  otherwise  it  is 
questionable  whether  the  operation  could  have  been  per- 
formed at  all,  the  patient  was  so  much  depressed.  He  had 
at  this  time  no  abdominal  uneasiness,  and  his  bladder  acted 
freely.  By  the  attentive  administration  of  mild  nourishment 
and  opiates,  this  patient  gradually  improved.  No  tender- 


238  SURGERY    OF    THE    CRIMEAN    WAR. 

ness  or  other  untoward  symptom  appeared  in  the  abdomen. 
The  wounds  assumed  a  sloughy  look  for  some  days,  and 
deep  cellular  inflammation  in  the  upper  part  of  the  thigh 
made  incisions  necessary.  On  the  fifth  day  his  bowels  were 
for  the  first  time  moved  by  the  aid  of  warm-water  enemata. 
At  this  time  the  wounds  were  granulating  kindly,  and  the 
stump  was  healing  well.  The  coil  of  intestine  was  still 
visible  at  that  date.  The  ala  of  the  ileum,  which  had  been 
laid  bare,  granulated  over,  but  most  of  the  crest  became 
loose,  and  was  removed  at  different  times.  The  bowels 
came  to  act  naturally,  and  without  any  stimulation,  and  by 
the  end  of  July  the  wound  on  the  abdomen  had  completely 
healed  by  granulation.  The  femur,  if  fractured — and  of  this 
there  was  every  symptom,  though  the  state  of  the  pelvis 
prevented  a  careful  examination  being  made — became  con- 
solidated, but  remained  two  inches  shorter  than  the  other. 
The  simplest  dressings,  and  almost  no  internal  treatment, 
were  followed  throughout  the  progress  of  the  case.  This 
patient  never  had  a  bad  symptom,  but  made  a  most 
excellent  recovery ;  and  when  he  went  to  England,  in  Sep- 
tember, all  his  wounds  had  healed  with  the  exception  of  two 
small  sinuses,  leading  to  dead  bone,  on  either  side  of  the 
great  trochanter.  Below  Poupart's  ligament,  and  external 
to  the  femoral  artery,  a  hard  mass  was  traceable  by  the 
touch,  which  appeared  to  be  some  part  of  the  pelvis  driven 
down  into  that  situation.  It  did  not  give  him  any  annoy- 
ance. The  limb,  though  shortened,  was  fully  movable  at 
the  hip-joint,  without  causing  pain,  and  he  could  raise  his 
knee,  but  not  his  heel,  from  the  bed.  The  shape  of  the  hip 
was  destroyed,  the  projection  of  the  crest  of  the  ileum 
gone,  but  that  of  the  great  trochanter  was  unnaturally 
increased. 

O'Neil,  private  in  the  38th  Regiment,  was  admitted, 
under  my  charge,  into  the  general  hospital  in  June.  A 
ball  entered  his  lefc  lumbar  region,  about  three  inches  from 
the  spine,  as  he  was  lying  on  the  ground  in  one  of  the  ad- 


WOUNDS  OF  THE  ABDOMEN  AND  BLADDER.     239 

vanced  trenches,  with  his  feet  toward  the  enemy's  works. 
The  ball  lodged.  The  finger  went  deeply  inward  and  some- 
what upward,  but  detected  nothing  of  the  ball,  the  situation 
of  which  could  by  no  means  be  made  out.  In  the  evening 
his  abdomen  became  a  little  tender,  his  pulse  hard,  and  his 
face  flushed.  He  was  once  bled,  opium  administered  freely, 
and  a  fomentation  applied  to  the  belly.  Next  day  the 
uneasiness  had  gone,  and  for  eight  days  there  was  no  return 
of  it  whatever.  His  alvine  evacuations  were,  in  the  mean 
time,  regulated  by  the  use  of  mild  clysters.  No  blood 
appeared  by  stool.  The  wound  suppurated  healthily.  He 
was  kept  on  very  mild  and  easily-digested  diet.  On  the 
eighth  day  severe  pain  suddenly  set  up  in  the  left  iliac 
region.  This  pain  was  increased  by  pressure,  but  was  very 
limited  in  its  extent.  He  vomited  frequently,  and  his  pulse 
rose  to  110  per  minute.  His  bowels  had  acted  freely  the 
day  before.  His  tongue  was  dry  and  furred.  He  had  a 
dozen  leeches  and  repeated  fomentations  applied  to  the 
abdomen.  Dover's  powder,  in  doses  of  gr.  x,  was  ordered 
every  second  hour.  Next  day  the  pain  had  quite  left,  and 
all  treatment  was  stopped.  His  bowels  did  not  act  without 
the  use  of  a  clyster.  He  got  plenty  of  mild  nourishment, 
and,  after  a  time,  cod-liver  oil.  Though  without  any 
uneasiness  or  symptom  of  ailment,  he  became  much  emacia- 
ted, but  ultimately  rallied,  and  made  a  good  recovery,  the 
position  of  the  ball  never  having  been  discovered,  though 
the  direction  and  depth  of  the  wound  would  appear  to 
favor  the  view  that  it  had  penetrated  the  cavity. 

I  saw  a  patient  in  one  of  the  French  hospitals  at  Con- 
stantinople whose  abdomen  had  been  traversed  from  behind, 
forward,  by  a  ball  at  Inkerman.  The  bullet  had  entered 
near  the  spine  of  the  last  dorsal  vertebra,  and  had  escaped 
near  to  but  slightly  to  the  left  of  the  umbilicus.  The  gut 
protruded  for  some  days  at  the  anterior  wound,  but  did  not 
appear  to  be  injured,  at  least  no  intestinal  secretion  showed 
itself  at  either  orifice.  Hardly  any  bad  symptoms  seemed 


240  SURGERY   OF    THE   CRIMEAN    WAR. 

to  have  followed.  The  gut  was  returned,  the  man  kept  low, 
and  opium  freely  administered.  He  made  a  most  excel- 
lent recovery.  In  another  patient  in  the  same  hospital, 
a  wound  of  exactly  the  same  description  had  been  inflicted. 
The  same  symptoms  and  result  followed,  except  that  the 
gut  did  not  protrude,  and  that  recovery  was  slower. 

The  following  was  a  very  remarkable  case,  which,  though 
not  strictly  a  wound  of  the  abdomen,  I  mention  here,  as  I 
do  not  intend  to  refer  to  gunshot  wounds  of  the  rectum.  I 
saw  the  patient  at  Scutari,  toward  the  end  of  1854,  under 
the  immediate  charge  of  Mr.  Price,  now  assistant-surgeon 
of  the  14th  Regiment.  A  ball  entered  the  front  of  a  soldier's 
left  thigh,  three  inches  above  the  patella,  as  he  was  mounting 
the  heights  at  Alma,  and  passed  upward  deep  among  the 
muscles  of  the  thigh.  It  then  turned  round  the  limb, 
traversed  the  muscles  of  the  left  hip,  crossed  the  perineum 
deeply,  and  escaped  on  the  right  hip,  having  passed  through 
the  rectum  some  way  above  the  anus.  The  wound  of  exit 
closed,  and  for  several  days  before  death  faeces  passed  by  the 
wound  above  the  knee.  Sloughing  and  irritative  fever  set 
in,  and  he  sank  rapidly. 

To  prevent  the  infiltration  of  faecal  matter  in  these 
cases,  Larrey  has  recommended  the  use  of  a  tube  in  the 
rectum. 

The  bladder  has  been  wounded  by  gunshot  several  times 
during  the  past  war,  but  the  returns  fail  to  tell  us  how  often. 

Balls  at  times  pass  through  the  pelvis,  and  yet  spare 
the  contents.*  Thus  in  one  case,  of  which  I  have  notes, 
it  passed  in  by  one  sacro-ischiatic  notch,  and  out  by  the 
other,  without  doing  more  mischief  than  contusing  the  rec- 
tum. When  the  bones  of  the  pelvis  are  broken,  the  injury 
is  very  serious,  from  their  deep  position,  neighborhood  to 

*  In  the  case  of  a  man  wounded  at  Chillianwallah,  a  six-pound 
grape-shot  passed  through  the  pelvis,  and  yet  he  survived  four 
days. 


WOUNDS   OP   THE   ABDOMEN   AND    BLADDER.  241 

important  vessels,  and  thick  covering.  Stromeyer  has  called 
attention  to  the  great  liability  there  is  to  pyaemia  after  such 
injuries.  If  the  ball  passes  through  the  peritoneum,  then 
the  risk  of  violent  inflammation  is  so  great  as  to  render  the 
wound  generally  fatal. 

The  bladder  may  be  wounded  in  many  directions  ;  but  the 
passage  of  the  ball  in  an  oblique  line  from  above  downward, 
and  to  either  side,  seems  the  most  common  course  for  it  to 
take.  Occasionally  its  superior  fundus  is  opened  by  a  ball 
passing  across  the  abdomen  from  side  to  side,  close  above 
the  symphysis  pubis.  The  gravity  of  the  wound  will  de- 
pend mainly  on  whether  the  peritoneum  has  been  injured  or 
not.  If  it  has  not  been  opened,  then  the  prognosis  will,  in 
some  measure,  hang  upon  the  empty  or  full  condition  of  the 
viscus  at  the  moment  of  penetration.  If  the  direction  of 
the  wound  permit  of  the  infiltration  of  urine  into  the  peri- 
toneum, then  the  fatal  issue  will  not  be  long  delayed.  These 
are  the  cases  whose  hopeless  nature  probably  gave  rise  to 
the  oft-quoted  Hippocratic  axiom,  "  Cui  persecta  vesica  le- 
thale;"  as  gunshot  wounds,  at  any  rate,  implicating  those 
parts  of  the  viscus  which  are  uncovered  by  serous  membrane, 
are  by  no  means  so  mortal  as  they  were  so  long  supposed. 
Dr.  John  Thomson  saw  in  Belgium  alone  fourteen  cases  in 
a  fair  way  of  recovery. 

A  ball  may  lodge  either  in  the  neighborhood  of  the  blad- 
der, or,  entering  its  cavity,  remain  there.  This  latter  result 
will  be  most  apt  to  occur  when  the  bladder  is  full  of  urine 
or  the  ball  much  spent  at  the  moment  of  contact.  In  rare 
cases,  a  ball,  when  very  small,  has  been  passed  with  the 
urine,  and  it  has  been  known  to  escape  by  the  formation 
and  opening  of  an  abscess  in  the  perineum. 

The  urine  may  escape  by  the  wound  at  once,  or  at  a  later 
period  when  the  eschar  separates  from  the  wound,  or  it  may 
not  escape  at  all.  It  is  seldom,  however,  that  it  fails  to  pass 
in  some  quantity  at  the  time  of  injury.  The  swelling  which 

21 


242  SURGERY   OF    THE    CRIMEAN    WAR. 

takes  place  in  the  lips  of  the  wound  prevents  in  a  great 
measure  the  flow  of  the  secretion  by  the  opening ;  but  it  is 
by  no  means  always  sufficient  to  do  so,  as  we  would  be  led 
to  suppose  from  Larrey's  statement.  The  urine  may,  and 
does  at  times,  escape  by  both  wounds,  if  the  ball  has  passed 
out;  but  from  the  greater  amount  of  bruising  and  swelling 
which  takes  place  at  that  of  entrance,  it  may  fail  to  appear 
there,  even  although  it  be  the  more  dependent,  and  flow  only 
from  the  wound  of  exit.  The  early  passing  and  retaining 
of  an  elastic  catheter  is  a  most  important  part  of  the  treat- 
ment of  these  cases,  as  it  prevents  the  urine,  in  traversing 
the  canal  of  the  wound,  from  becoming  infiltrated  among 
the  divided  tissues.  Larrey,  recognizing  the  existence  of 
this  danger  only  at  the  period  of  separation  of  the  eschars,  did 
not  employ  a  catheter  early,  but  was  particular  in  its  use  at 
the  period  when  he  thought  the  accident  referred  to  was 
most  apt  to  occur.  Moreover,  the  fact  that  the  slough  is 
by  no  means  the  barrier  to  infiltration  which  he  supposed  it 
to  be  is  now  well  recognized,  as  well  as  that  the  exact  period 
when  its  separation  is  to  be  looked  for,  we  know,  cannot  be 
relied  on.  The  irritation  and  straining  which  the  unevacu- 
ated  urine  occasions  may  prematurely  force  off  the  slough, 
and  allow  the  urine  to  become  effused,  and  so  the  mischief 
may  be  done  before  we  are  ready  to  combat  it.  Unless  the 
wound  implicate  the  neck  of  the  bladder,  the  presence  of  a 
gum  catheter  will  create  but  little  irritation,  and  should  be 
enjoined  from  the  moment  of  injury.  The  catheter  had  best 
be  retained  till  the  urine  begins  to  flow  by  its  side,  as  the 
formation  of  abscesses,  with  their  disagreeable  and  dangerous 
consequences,  is  thus  more  safely  guarded  against. 

Larrey,  with  the  object  of  obviating  infiltration  and  venous 
engorgement,  had  recourse  to  scarifications,  so  as  to  enlarge 
the  wound  and  prevent  all  retention  of  secretion  in  its  track. 
This  step  will,  however,  be  perfectly  uncalled  for,  if  the  cath- 
eter be  retained  from  an  early  period.  Rest,  low  diet,  mu- 
cilaginous drinks,  enemata,  it  may  be  leeches,  and  fomenta- 


WOUNDS  OF  THE  ABDOMEN  AND  BLADDER.     243 

tions,  or  hip  baths,  will  comprise  the  rest  of  the  treatment 
in  the  majority  of  cases.  The  employment  of  morphia  sup- 
positories will  also  be  found,  under  certain  circumstances, 
most  useful.  If  any  urine  does  escape  into  the  tissues,  its 
early  evacuation  will  of  course  be  necessary. 

The  posterior  or  lower  wound  commonly  closes  before  the 
anterior ;  but  neither  ought  to  remain  long  open,  if  the 
catheter  be  made  to  remove  the  urine  so  soon  as  it  enters 
the  bladder.  If  the  part  through  which  the  ball  has  passed 
be  deep,  the  external  orifice  of  the  wound  may  close  before 
the  rest  of  the  track — a  result  which  should  be  avoided. 

The  position  of  the  bladder,  its  depth  from  the  surface, 
its  size  internally,  the  want  of  correspondence  which  takes 
place  between  the  external  wound  and  that  in  its  walls  from 
their  contraction  after  the  passage  of  the  ball,  make  the  ex- 
traction of  a  ball  by  the  wound  a  matter  of  impossibility 
without  such  an  enlargement  of  the  orifice  as  would  be  in- 
jurious. 

If  the  ball  remains  in  the  bladder,  it  becomes  a  matter  of 
moment  to  remove  it.  Balls,  pieces  of  cloth  or  bone,  so 
introduced,  form  the  nucleus  of  calculi ;  so  that  the  sooner 
they  are  got  quit  of  the  better,  provided  the  immediate  irri- 
tation and  inflammation  caused  by  the  wound  have  subsided. 
Many  cases  are  now  on  record  in  which  the  bladder  has 
been  opened,  and  calculi,  having  balls  as  their  nuclei,  have 
been  removed.  Larrey  operated  successfully  on  the  fourth 
day  after  the  introduction  of  the  ball,  and  mentions  a  case 
in  which  Langenbeck  succeeded  in  removing  a  similar  body 
ten  years  after  its  introduction  into  the  bladder.  Morand 
operated  twice.  Demarquay  mentions  a  case  in  which  the 
nucleus  was  a  piece  of  shell.  Baudens  successfully  removed 
the  ball  by  an  incision  above  the  pubis ;  Guthrie,  by  the  lat- 
eral operation.  Hutin  mentions  two  cases  in  which  a  ball 
or  foreign  body  was  removed  by  lateral  incision — one  after 
thirty-two  years'  and  the  other  after  nineteen  years'  resi- 
dence in  the  bladder  In  one  of  these  cases,  three  calculi 


244  SURGERY   OF   THE    CRIMEAN    WAR. 

were  removed,  having  pieces  of  cloth  as  their  nuclei.  Be- 
sides these,  Mr.  Dixon,  in  the  33d  volume  of  the  Medico- 
Chirurgical  Transactions,  has  given  the  particulars  of  ten 
other  cases  in  which  balls  were  successfully  removed,  and 
three  in  which  the  attempt  failed.  Nearly  all  of  these  pa- 
tients were  operated  on  years  after  being  wounded.  In  the 
Medical  Examiner  for  1855  a  case  is  recorded  in  which  a 
large  ball,  driven  into  the  bladder,  was  not  found  till  two 
years  after,  on  the  death  of  the  patient.  It  formed  the  cen- 
ter of  a  large  calculus  concretion. 

The  following  case  I  find  detailed  in  the  Report  from  the 
sanitary  depot  at  Landour  for  1849-50  :*  Private  West 
was  wounded  on  the  hip  by  a  grape-shot  at  Chillianwallah. 
The  ball  was  lost,  and  the  wound  healed  kindly  in  six  weeks. 
A  day  or  two  after  being  wounded,  he  experienced  a  scald- 
ing sensation  in  the  urethra  on  micturating,  and  he  showed 
marks  of  a  urethral  discharge  on  his  linen,  which  he  thought 
was  a  return  of  an  old  gonorrhoea.  He  was  treated  under 
this  idea  for  a  time,  the  symptoms  of  inflammation  in  the 
bladder  being  ascribed  to  the  gonorrhoea.  The  attacks  of 
cystitis  became  so  severe  as  to  cause  his  bladder  to  be  ex- 
amined, when  a  hard  substance  was  discovered.  The  intro- 
duction of  the  instrument  gave  great  pain,  and  it  was  only 
on  the  second  trial  that  a  foreign  body  was  detected.  By 
the  lateral  operation  a  grape-shot  was  found  and  extracted, 
"slightly  incrusted  with  a  sandy  deposit."  He  recovered 
perfectly.  No  bone  was  injured  by  the  ball.  "After  the 
operation,  the  patient  remembered  that  he  used  to  pass 
blood  and  pus  in  his  fa3ces  after  he  was  wounded.  Hence 
it  is  probable  that  the  ball  entered  by  the  sciatic  notch,  and 
traversed  the  rectum,  entering  the  bladder  at  its  back  part." 


*  Unpublished  records  of  Medical  Department.  This  case  is  re- 
ferred to  by  Guthrie.  and  has  been  recorded  by  Mr.  M'Pherson,  in 
connection  with  Mr.  Dixon's  paper,  but  with  some  variation  from  the 
account  given  in  the  text. 


WOUNDS   OP   THE    ABDOMEN    AND    BLADDER.  245 

The  following  is  a  fair  example  of  a  penetrating  wound 
of  the  bladder : — 

Griffith,  private  5Tth  Regiment,  was  admitted  into  the 
general  hospital  in  the  summer  of  1855.  A  ball  had  entered 
his  left  hip,  close  to  the  tuber  ischii,  and  escaped  on  the  ab- 
domen, two  inches  above  the  symphysis,  a  little  to  the  right 
of  the  middle  line.  Urine  escaped  by  the  anterior  opening. 
A  catheter  was  passed  into  the  bladder  and  retained  there. 
He  had  no  bad  symptoms  of  any  kind  for  twelve  days.  His 
urine  passed  by  the  catheter,  and  also  by  the  opening  on 
the  abdomen.  His  pulse  remained  quiet,  and  his  abdomen 
without  uneasiness.  His  general  health  was  unimpaired, 
and  his  bowels  acted  regularly.  The  posterior  wound, 
through  which  urine  never  passed,  closed  rapidly.  On  the 
twelfth  day  he  had  severe  pain  in  the  abdomen,  which  was, 
however,  relieved  by  a  dose  of  opium,  and  he  never  after- 
ward had  a  bad  symptom  or  uneasy  feeling,  except  the  irri- 
tation occasioned  by  the  urine  flowing  on  the  abdomen, 
which  could  not  be  altogether  prevented.  His  urine  was 
loaded  with  mucus  and  pus  during  the  period  of  cure,  and 
he  passed  several  small  pieces  of  bone,  both  by  the  urethra 
and  by  the  abdominal  wound.  At  the  end  of  six  weeks  he 
could  retain  his  urine,  and  pass  it  at  pleasure  by  the  natural 
passage  in  a  full  stream.  For  a  mouth  he  had  been  unable 
to  prevent  his  urine  flowing  constantly  away.  In  about  two 
months  from  the  period  of  his  admission  the  wound  on  the 
abdomen  was  completely  closed  by  the  use  of  nitrate  of  sil- 
ver. His  strength,  which  had  somewhat  failed,  was  at  that 
time  quite  restored,  and  he  was  walking  about  the  ward  con- 
valescent. At  this  period  he  passed  from  under  my  notice ; 
but  I  learned  that  the  wound  on  the  abdomen  had  reopened, 
and  that  he  could  pass  his  urine  without  any  pain  through 
this  opening  in  a  continuous  stream,  but  that  ultimately,  be- 
fore he  went  to  England,  it  had  permanently  closed. 

The  following  case  is  curious,  as  showing  how  large  a  body 
21* 


246  SURGERY    OP    THE    CRIMEAN    WAR. 

may  descend  into  the  pelvis,  and  yet  very  slightly  injure  the 
viscera :  A  soldier  at  the  Alma  was  wounded  by  a  piece  of 
shell,  which  struck  him  over  the  symphysis  pubis,  and,  de- 
scending into  the  pelvis,  was  lost.  No  bad  symptom  what- 
ever supervened,  and  he  made  a  rapid  recovery.  The  sur- 
geon in  charge  of  the  case  thought  that  the  missile  lay 
impacted  deep  in  the  pelvis,  behind  the  pubes,  but  this  he 
could  not  satisfactorily  determine.  Here  the  bladder  escaped 
most  miraculously. 

The  injury  was  much  more  severe,  but  the  result  little  less 
fortunate,  in  the  following  case  :  A  French  soldier  of  the 
line  was  struck  at  the  Alma  by  a  piece  of  shell,  above  the 
symphysis  pubis,  which  fractured  the  bones,  passed  down- 
ward, and  was  removed  in  the  perineum  from  the  side  of 
the  urethra.  The  rectum  and  urethra  were  both  lacerated. 
Deep  abscesses  formed,  the  patient's  strength  gave  way,  but 
no  acute  attack  of  inflammation  seized  any  of  the  viscera. 
A  communication  was  established  between  the  bladder  and 
rectum,  and  between  the  bladder  and  the  abdominal  wall,  so 
that  gas  and  small  pieces  of  faeces  escaped  at  times  on  the 
abdomen.  Blood  frequently  passed  by  the  urethra.  The 
last  time  I  saw  this  man  was  in  January,  1855,  when  he  was 
recovering  rapidly. 

In  the  next  case  the  missile  penetrated  the  pelvis  from 
below,  and  it  is  interesting  chiefly  from  the  manner  in 
which  the  peritoneum  escaped.  A  French  artilleryman  was 
wounded  at  the  battle  of  the  Alma  by  a  piece  of  shell,  which 
struck  him  on  the  perineum,  and  penetrated  between  the 
rectum  and  bladder,  establishing  a  fistulous  communication 
between  these  parts.  The  peritoneum  was  not  opened.  No 
bad  symptom  followed,  but  when  he  was  sent  home  he  was 
dying  of  phthisis. 

There  is  a  case  related  in  one  of  the  Indian  reports,  which 
illustrates  in  a  curious  way  the  severe  injury  which  the  peri- 
neum may  undergo.  A  soldier  of  the  14th  Light  Dragoons 


WOUNDS  OF  THE  ABDOMEN  AND  BLADDER.     24 1 

had  the  pommel  of  his  saddle  struck  by  a  round  shot  at 
Goojerat.  The  ball  passed  under  and  between  him  and  his 
horse,  which  escaped  injury.  The  rami  of  the  ischium  and 
pubes  were  fractured  on  the  left  side,  the  perineum  exten- 
sively lacerated,  but  the  scrotum  was  only  slightly  abraded, 
and  the  urethra  was  uninjured.  He  had  much  pain  after- 
ward in  passing  his  urine ;  the  soft  parts  of  the  perineum 
sloughed,  and  his  testicles  atrophied,  but  otherwise  he  made 
a  good  recovery. 


CHAPTER  X. 


COMPOUND    FRACTURES   OF   THE    EXTREMITIES,   GUNSHOT 
INJURIES    OF    THE    HAND   AND    FOOT. 

In  the  returns  of  the  late  war,  from  April  1st,  1855,  2198  cases  of  gunshot 
wounds  of  the  lower  extremities  appear  among  the  men,  and  166  deaths 
therefrom.  Of  these,  1628  cases  and  55  deaths  were  mere  flesh  wounds, 
and  43  cases  and  2  deaths  wounds  with  contusion  and  partial  fracture 
of  long  bones;  23  cases  and  1  death,  simple  fracture  of  long  bones  by 
contusion  of  round  shot;  174  cases  and  64  deaths  from  compound  frac- 
ture of  the  femur;  66  cases  and  9  deaths  from  the  same  injury  of  the 
tibia  or  fibula  alone;  144  cases  and  27  deaths  from  compound  fracture 
of  both  bones  of  the  leg ;  88  cases  and  7  deaths  from  perforating  or 
penetrating  wounds  of  the  tarsus.  Besides  those  who  died  directly  from 
the  injury,  96  cases  of  compound  fracture  of  the  femur,  and  91  cases  of 
compound  fracture  of  both  bones  of  the  leg,  were  submitted  to  ampu- 
tation. 

There  were  1237  cases  and  8  deaths  from  flesh  wounds  of  the  upper  ex- 
tremity ;  102  cases  and  12  deaths  from  contusion  and  partial  fracture 
of  the  long  bones,  (including  the  clavicle  and  scapula;)  27  cases  and  2 
deaths  from  round  shot  simple  fractures;  169  cases,  15  deaths,  and  104 
submitted  to  amputation,  from  compound  fraction  of  the  humerus;  66 
cases,  2  deaths,  and  41  amputations  from  compound  fracture  of  the  bones 
of  the  forearm.  In  113  cases  the  structures  of  the  carpus  were  pene- 
trated or  perforated,  and  48  of  these  cases  were  subjected  to  amputation. 

OF  all  the  severe  injuries  received  in  battle,  none  are  of 
more  frequent  occurrence  or  of  more  serious  consequence 
than  compound  fractures.  They  cause  peculiar  anxiety  to 
the  surgeon,  from  the  manner  in  which  their  extent  and 
gravity  are  so  often  masked,  and  from  the  uncertainty  which 
still  prevails  as  to  many  points  in  their  treatment.  This 
ambiguity  as  to  their  management  arises  in  a  great  measure 
from  the  many  varying  causes  connected  with  the  state  of 
(248) 


COMPOUND   FRACTURE   OP   THE   EXTREMITIES.         249 

health  of  the  patient,  and  the  means  at  hand  for  his  treat- 
ment— circumstances  which  fluctuate  with  every  campaign. 

In  the  Crimea,  these  injuries  were  peculiarly  embarrassing 
and  extraordinarily  fatal.  In  the  management  of  no  acci- 
dents was  so  much  expected  from  modern  improvements, 
and  by  none  were  we  so  much  disappointed  in  the  results. 
It  was  confidently  hoped  that  in  very  many  of  those  cases 
which,  in  the  old  wars,  would  have  been  condemned  to  am- 
putation, the  limb  would  now  be  preserved,  either  by  the 
exercise  of  greater  care  in  the  treatment,  or  by  having 
recourse  to  some  of  the  modern  expedients  by  which  limbs 
are  so. often  saved  at  home.  But,  unfortunately,  a  sad  expe- 
rience only  confirmed  the  hopeless  nature  of  compound  frac- 
tures of  the  thigh  by  gunshot,  and  their  very  uncertain  and 
dangerous  character  when  the  leg  or  arm  are  implicated. 

In  the  following  remarks  on  compound  fracture,  I  propose 
to  refer  chiefly  to  those  cases  in  which  the  femur  was  broken, 
and  I  will  notice  afterward  similar  injuries  of  the  leg  and 
arm. 

It  can  hardly  be  doubted  that  the  great  striving  after 
conservatism,  which  influenced  all  the  surgeons  of  our  army, 
was  one  main  cause  of  that  mortality  which  attended  these 
injuries.  We  were  not  prepared  to  believe  how  hopeless 
they  were,  till  the  unwelcome  truth  was  forced  upon  us  by 
an  ever-recurring  experience.*  We  were  disposed  to  judge 

*  "When  the  brigade  was  first  landed,  an  opinion  prevailed  that 
cases  of  compound  fracture  of  the  thigh  would  be  met  with  in  which 
it  would  be  proper  to  attempt  to  save  the  limb,  and  every  case  was 
carefully  examined  in  order  to  determine  the  kind  of  treatment  it 
would  require.  Two  cases  were  at  length  brought  into  the  camp, 
respecting  which  the  majority  of  the  medical  officers  were  of  opinion 
that  amputation  should  not  be  performed.  The  men  were  both 
young,  healthy,  and  temperate;  the  injury  to  the  bone  and  soft  parts 
comparatively  slight  in  both  cases.  The  external  wound  was  small, 
and  situated  on  the  outer  side  of  the  limb  in  one,  two,  or  three 
inches  below  the  trochanter;  in  the  other,  the  same  distance  above 
the  knee.  The  result  of  the  former  was,  after  great  suffering, 


250  SURGERY   OF   THE   CRIMEAN    WAR. 

of  compound  fractures  by  gunshot  as  we  would  of  accidents, 
similar  at  least  in  name,  seen  in  civil  life.  Full  of  the  prom- 
ise of  the  schools,  we  would  not  admit  that  any  injury  appa- 
rently so  slight  could  withstand  the  assiduities  of  a  wise 
conservatism.  In  trying,  however,  to  save  limbs  we  lost 
many  lives,  thus  fulfllling  the  prophecy  of  one  of  the 
greatest  surgeons.*  Cases  of  promising  appearance  were 
reserved  for  the  trial  —  the  very  cases,  in  fact,  which  would 
have  made  the  best  recoveries  if  operated  upon  early,  and 

death.  In  the  latter,  although  the  patient  recovered,  there  is  little 
prospect  of  the  limb  ever  becoming  useful.  Experience  has  therefore 
forced  upon  us  the  conviction  that  to  attempt  to  save  the  limb  in  any 
case  of  compound  fracture  of  the  thigh,  the  result  of  gunshot,  is  to 
endanger  the  patient's  life;  and  the  result  of  secondary  amputation 
has  not  been  such  as  to  induce  us  to  trust  to  that  chance  of  saving 
life  after  the  failure  of  the  first  attempt." — Report  of  Black  Sea 
Fleet,  p.  36. 

*  How  similar  has  been  the  slow  process  of  conviction  on  this  head, 
is  well  shown  in  the  following  remarks  of  M.  Gaultier  de  Claubry, 
quoted  by  Paillard  in  a  note:  "Lorsque  j'arrivai  sur  le  theTitre  de 
la  chirurgie  militaire,  je  me  permis  de  blamer  hautement  la  conduite 
de  mes  chefs,  que  j'appelais  aussi  routiniere,  barbare;  jeparvins  rneme, 
a  force  d'instances,  a  force  d'assurance  des  resources  de  la  nature  et 
de  1'utile  secours  de  1'art,  a  porter  quelques  chirurgiens  militaires  a 
douter  de  la  justesse  de  leurs  determinations;  a  hesiter,  dans  certains 
cas,  a  s'armer  de  1'instrument  tranchant.  Eh  bien  !  les  plus  experi- 
mentes  m'assauraient  quejene  tarderais  pas  a  revenir  de  monerreur; 
les  autres  ne  tarderent  point  a  gernir  avec  moi,  eux,  de  leur  blamable 
condescendance,  et  moi,  de  la  presomptueuse  16gerete  avec  laquelle 
j'avais  juge,  une  conduite  sanctionee  par  une  longue  experience,  sans 
avoir  reuni  tous  les  elements  de  la  question.  J'ai  encore  presents  a 
I1  esprit  les  nombreux  blesses  de  la  compagne  de  1805,  en  Italic,  chez 
lesquels  je  passais  des  journees  entieres  a  panser  des  fractures  com- 
minutives  des  os  longs,  et  qui  succomberent  tous,  les  uns  dans  les 
premieres  jours,  par  1'effet  des  accidents  primitifs,  douleurs,  convul- 
sions, fievre,  resorption  purulente ;  les  autres  apres  un  temps  quel- 
quefois  fort  long,  lorsque  leurs  blessures  avaient  eprouve  un  notable 
aiueudemente,  par  1'effet  du  typhus  nosocomial,  de  la  dyscnterie 
e'pidemique',"  etc. 


COMPOUND   FRACTURE    OF    THE   EXTREMITIES.          251 

the  inevitable  amputation  was  delayed  till  the  patient's  con- 
stitution had  become  so  depressed  as  to  be  beyond  reaction. 

Two  circumstances  seem  to  have  had  chiefly  to  do  with 
the  irreparable  character  and  mortality  of  compound  frac- 
tures of  the  thigh  in  the  Crimea — first,  the  state  of  health 
of  the  men  when  wounded;  and,  secondly,  the  effect  on 
bone  of  the  new  kind  of  ball  with  which  most  of  these  in- 
juries were  inflicted. 

As  to  the  state  of  health  of  our  patients,  it  was  not 
merely  that  they  were  in  so  anemic  a  condition  that  suppu- 
ration and  irritation  quickly  prostrated  them;  nor  was  it 
that  their  stamina  and  "  pluck"  had  been  destroyed  by  hard- 
ship and  suffering;  nor  that  the  means  of  treating  them  in 
front  during  the  early  period  of  the  war  were  totally  want- 
ing; but  the  chief  cause  of  the  reluctance  shown  by  nature 
to  repair  the  osseous  breach  was  the  scurvy-poison  which 
held  command  in  their  systems.  This  it  was  which  mainly 
opposed  recovery.  Callus  was  not  thrown  out  at  all;  or  if 
it  was,  it , refused  to  consolidate.  I  myself  examined  the 
limbs  of  a  large  number  of  men  who  died  at  Scutari  during 
the  early  part  of  the  war,  and  in  not  a  single  instance 
almost  did  I  observe  the  slightest  attempts  at  repair;  but, 
on  the  contrary,  invariably  found  a  large  sloughing  chamber 
filled  with  dead  and  detached  fragments  of  bone,  shreds  of 
sloughing  muscle  and  destroyed  tissue  into  which  the  black 
and  lifeless  bones  projected  their  irregular  extremities,  and 
across  which,  lying  in  every  direction,  but  seldom  in  the  axis 
of  the  limb,  were  dead  and  detached  sequestra,  the  "  frac- 
ture-splinters "  of  the  accident. 

The  depressed  condition  of  body  to  which  the  hardships 
of  the  war  had  reduced  the  men  made  a  severe  compound 
fracture  of  the  femur  synonymous  with  death ;  so  that  we 
might  with  perfect  appropriateness  use  the  words  of  Ravan- 
ton  :  "1  exhausted  many  times  the  resources  of  art  without 
success — incisions,  removal  of  the  fragments,  early  bleed- 
ings of  sufficient  magnitude,  spare  diet,  dressings,  position, 


252  SURGERY   OF   THE    CRIMEAN    WAR. 

infinite  care,  nothing  could  protect  them  against  an  inevit- 
able death."  Most  of  our  patients,  as  I  before  remarked, 
had  either  suffered  from  dysentery  or  were  on  the  verge  of 
falling  into  that  disease.  The  vast  majority  of  them  had 
ulcerated  intestines,  and  were  thus  in  a  condition  of  health 
which  did  not  bear  disease.  When  men  in  this  state  re- 
ceived a  severe  compound  fracture,  and  their  constitutions 
were  taxed  to  repair  the  injury,  there  was  no  reserved  fund 
on  which  to  draw.  They  had  been  living  up  to  their  income 
of  health,  and  so  utter  failure  was  the  sure  result  of  increased 
expenditure.  If  when  injured  they  had  been  taken  into  the 
ward  of  a  London  hospital,  I  doubt  whether  they  would  in 
most  cases  have  ended  more  fortunately,  either  by  preserving 
the  limb  or  by  amputation  :  how  much  less,  then,  when  they 
had  to  undergo  treatment  in  a  camp  ! 

Many  of  our  patients  looked  very  well  at  first — appeared, 
perhaps,  strong  enough,  and  expressed  such  a  confident  hope 
in  the  result  as  almost  to  deceive  their  surgeon.  The  injury 
might  not  appear  very  severe ;  the  bone  was  undoubtedly 
broken,  but  it  might  not  be  much  comminuted  ;  and  thus  we 
flattered  ourselves,  and  began  a  trial  hopefully  which  always 
ended  in  disappointment.  The  golden  opportunity  was  al- 
lowed to  pass,  and  so  we  entered  on  a  road  which  led  to 
death,  whether  through  the  portal  of  amputation  or  any 
other.  The  struggle  soon  began.  Suppuration  set  in.  The 
disease  which  lurked  in  "blood  and  bone"  showed  itself. 
Diarrhoea  appeared  and  would  not  cease.  The  patient's 
stomach  refused  the  only  food  which  could  be  procured. 
He  got  emaciated,  weak,  and  irritable.  A  suspicion  was 
awakened  that  the  bone  had  been  more  severely  "injured 
than  was  at  first  supposed.  Things  went  on  from  bad  to 
worse.  Hectic  claimed  its  share  of  the  waning  strength ; 
and  whether  we  operated  late  or  not,  the  great  regret  re- 
mained that  it  was  not  done  at  first,  as  the  invariable  result 
demonstrated  the  uselessness  of  any  other  proceeding. 

During  the  greater  part  of  the  siege,  the  means  of  treat- 


COMPOUND   FRACTURE   OF   THE   EXTREMITIES.          253 

ing  these  accidents,  whether  as  regards  food,  bedding,  clothes 
or  shelter,  did  not  exist  in  camp;  and  to  transfer  them  to 
the  rear  only  made  the  fatal  result  the  more  certain,  from 
the  pysemic  poisoning  which  was  sure  to  be  set  up  by  the 
transport.  Thus,  then,  it  came  to  be  that  up  to  the  period 
when  things  were  improved  in  the  camp  hospitals  and  in  the 
transport  service,  recovery  from  a  compound  fracture  of  the 
thigh  was  impossible,  or  nearly  so,  and  that  the  best  hope 
lay  in  an  early  amputation.  The  only  exception  to  this  I 
will  afterward  allude  to. 

Now,  while  it  may  with  seeming  truth  be  said  that,  as 
most  of  these  circumstances  were  peculiar  to  the  Crimean 
war,  the  principles  deducible  from  them  are  not  of  universal 
application,  still  many  of  them  are  inseparably  connected 
with  warfare. 

It  is  essential  to  the  successful  treatment  of  compound 
fractures,  that  the  patient  be  supplied  with  suitable  food, 
that  his  broken  limb  should  be  retained  for  a  certain  time- 
immovably  fixed  in  a  proper  apparatus,  and  that  it  be  care- 
fully and  regularly  dressed.  But  how  can  these  things  be 
guaranteed  in  war  ?  In  a  siege  they  ought  to  be  more  feas- 
ible than  in  any  other  kind  of  campaign ;  but  how  was  it 
with  us  ?*  Besides  the  privations  which  most  armies 
undergo,  there  is  the  inevitable  shifting  of  position,  and 
of  the  wounded,  unless  the  plan  Esraarch  tells  us  they 


*  At  the  siege  of  Antwerp,  where  every  convenience  existed,  and 
the  men  in  good  health,  their  experience  was  no  more  favorable  than 
usual.  In  the  Sleswick-Holstein  war  they  saved  a  few — the  hard- 
ships being  very  greatly  less  than  those  which  can  be  looked  for  in 
any  other  war.  In  India,  also,  a  good  many  compound  fractures 
were  cured  ;  but  then  the  difference  between  the  match-lock  ball  and 
the  conical  is  very  great.  The  Sikhs  used  a  ball  which  weighed  only 
3  drachms  and  40  grains  Troy,  and  had  very  much  less  propulsive 
force  than  ours,  as  is  evidenced  by  the  number  of  cases  mentioned 
in  the  Reports,  in  which  they  failed  to  penetrate,  or  did  so  only 
superficially.  The  Chinese  match-lock  was  also  a  weak  weapon. 

22 


254  SURGERY   OF   THE   CRIMEAN   WAR. 

adopted  in  Holstein  be  followed,  and  the  patients  left  to  fall 
into  the  hands  of  the  enemy  in  order  to  obviate  the  necessity 
of  transport;  but  I  fear  there  are  few  medical  services  which 
could  afford  to  do  as  he  proposes,  viz.,  leave  a  certain  num- 
ber of  their  body  to  be  taken  prisoners,  in  order  to  secure 
the  unremitting  and  careful  treatment  of  the  cases.* 

So  much  for  the  health  of  our  men;  let  me  now  refer  to 
the  second  cause,  which,  I  believe,  rendered  our  fractures  so 
unmanageable.  There  cannot  be  a  doubt  that  the  old  round 
ball,  if  fired  at  a  certain  range,  comminuted  bone,  but  it  is 
equally  certain  that  at  a  longer  or  shorter  distance,  it  fre- 
quently failed  to  do  so.f  When  fired  a  few  hundred  yards 
off,  it  had  hardly  force  to  enter  the  body,  but  might  be 
diverted,  as  it  has  been,  by  the  point  of  the  nose.  If  it  did 
enter,  and  impinge  upon  bone,  it  might  only  dent  it,  as  may 
be  seen  by  an  example  in  the  Muse'e  Dupuytren,  in  Paris; 
or  it  might  groove  it  merely,  or,  penetrating  the  substance  of 
.the  bone,  it  might  remain  at  rest  without  splitting  it,  as  can' 
be  verified  in  any  museum  of  a  military  hospital.  If  fired 
again,  at  close  range,  the  round  ball  might  go  through  a 
bone,  making  a  bore  as  clean  and  sharp  as  if  formed  by  a 

*  "Thus  we  foresee,"  says  John  Bell,  "an  argument  of  necessity 
as  well  as  of  choice,  and  that  limbs  which  in  happier  circumstances 
might  have  been  preserved,  must  often,  in  a  flying  army  or  in  a  dan- 
gerous camp,  be  cut  off.  It  is  less  dreadful  to  be  dragged  along  with 
a  neat  amputated  stump  than  with  a  swollen  and  fractured  limb, 
where  the  arteries  are  in  constant  danger  from  the  splintered  bones; 
and  where,  by  the  least  rude  touch  of  a  splinter  against  some  great 
artery,  the  patient  in  a  very  moment  loses  his  life." 

f  I  believe  that  the  proportion  of  cases  in  which  balls  have  passed 
through  the  fleshy  p-irJs  of  an  extremity  without  fracturing  the  bone, 
will  be  found  to  be  much  less  in  the  Crimean  than  in  other  wars. 
Thus,  in  one  series  of  cases  mentioned  by  Deputy-Inspector  Franklin 
in  his  report  on  the  wounded  at  Meanee,  31  cases  of  match-lock 
wounds  of  the  upper  arm  are  given,  and  in  only  one  was  the  bone 
broken.  To  work  out  this  point  in  figures  so  extensive  as  to  be  of 
any  use,  would  require  details  not  supplied  by  writers  on  the  old 
wars. 


COMPOUND   FRACTURE   OF   THE   EXTREMITIES.  255 

punch.  Of  this  fact  many  illustrations  can  be  seen  in  surgi- 
cal museums.  Now,  so  far  as  my  observation  goes,  none  of 
these  results  follow  the  stroke  of  a  heavy  conical  ball,  such 
as  that  used  by  the  Russians,  at  whatever  range  it  is  fired. 
It  never  rests  in  a  bone,  channels  or  perforates  its  substance, 
without  splitting  it,  like  a  wedge ;  nor  does  it  ever  come  to 
mark  a  bone  with  any  touch  more  gentle  than  what  occa- 
sions its  utter  destruction.  In  the  Crimea  we  had  many 
opportunities  of  observing  the  action  of  both  kinds  of  ball, 
and,  so  far  as  I  could  judge,  their  effects  were  so  dissimilar 
as  almost  to  justify  a  classification  of  injuries  founded  on  the 
kind  of  ball  giving  rise  to  them.*  The  longitudinal  split- 
ting of  the  bone  is  so  dextrously  and  extensively  accom- 
plished by  these  balls  that,  while  but  a  small  opening  may 
lead  to  the  seat  of  fracture,  the  whole  shaft  may  be  rent 
from  end  to  end.  I  have  repeatedly  seen  the  greater  part 
of  the  femur  so  split.  Stromeyer  has  shown  that  this  longi- 
tudinal splitting  seldom  transgressed  the  line  of  the  epiphy- 
sis,  an  observation  which  I  can  most  decidedly  confirm;  for 
though  the  injury  has  at  times  been  sufficiently  severe  to  im- 
plicate both,  yet  the  rule  has  been  just  as  he  says. 

Gunshot  fractures  of  the  long  bones  of  the  extremities 
have  always  been  considered  dangerous,  chiefly  on  account 
of  the  shock,  the  comminution  of  bone,  and  the  fact  that 
the  wound  leading  to  it  is  of  such  a  character  that  it  can 
heal  only  by  suppuration,  and  cannot  be  so  closed  as  to  con- 
vert it  into  a  simple  fracture,  which,  it  is  well  known,  we 
can  sometimes  accomplish  in  such  fractures  as  present  them- 
selves to  us  in  civil  practice.  The  cavity  of  the  fracture  is 
thus  kept  open  to  the  air;  the  pus  undergoes  those  changes 
which  Bonnet  has  shown  it  does  under  such  circumstances, 

*  In  these  remarks  I  refer  merely  to  the  heavy  conical  ball,  as 
there  are  balls  of  the  same  shape,  but  of  less  weight,  which  are  by 
no  means  so  formidable.  That  used  in  the  Sleswick-Holstein  cam- 
paigns appears  to  have  been  very  trivial  in  comparison  to  the  large 
Russian  one,  of  which  we  had  such  dire  experience. 


256  SURGERY   OP   TIIE   CRIMEAN    WAR. 

and  that  severe  and  prolonged  inflammation  of  the  deep  and 
irritable  tissues,  which  constitutes  the  chief  danger  in  com- 
pound fractures,  cannot  be  avoided.*  Now,  all  of  these 
dangerous  characteristics  of  compound  fractures  have  been 
immensely  increased  by  the  conical  ball.  First  of  all,  the 
shock  it  occasions  is  undoubtedly  greater  than  that  caused 
by  the  round  ball,  simply  because  the  destruction  it  causes  is 
much  more  severe.  Secondly,  the  comminution  of  bone  is 
enormously  increased ;  the  number  of  fragments  which  are 
quite  detached  are  much  more  numerous,  and  the  amount  of 
sequestra,  which  are  so  far  severed  as  to  be  ultimately 
thrown  out  before  a  cure  can  be  looked  for,  is  much  greater. 
Thirdly,  the  bruising  of  the  soft  parts  is  more  extensive,  so 
that  the  suppuration  is  more  prolonged,  and  the  changes  of 
purulent  absorption  so  much  the  more  multiplied. 

The  great  loss  of  substance  which  follows  compound  frac- 
tures by  the  conical  ball  is  the  source  of  one  peculiarity  in 
their  treatment.  The  shortening  will  be  greater  should  con- 
solidation follow,  than  if  the  injury  had  been  occasioned  by 
the  round  ball.  The  conviction  has  been  strongly  impressed 
upon  my  mind,  by  the  observation  of  not  a  few  of  these 


*  "All  the  complete  fractures  of  the  other  bones  of  the  extremi- 
ties unite  when  they  are  well  managed;  by  what  fatality  are  those 
of  the  femur  not  equally  fortunate  ?  Is  it  the  diameter  of  the  cavity 
of  the  bone;  the  quantity  of  medullary  substance  which  it  contains; 
the  peculiar  structure  of  the  vessels  which  carry  the  nourishment; 
the  size  and  force  of  the  muscles  which  are  attached  to  it,  which,  by 
their  weight  and  pressure,  obstruct  the  passage  of  the  liquids?  All 
these  causes  united  may  combine  together,  and  give  rise  to  that  want 
of  success  which  we  meet  with  in  treating  complete  fractures  of  the 
femur,  caused  by  firearms;  but  complete  fractures  of  this  bone  heal 
very  well,  whatever  cause  has  produced  them,  when  they  are  not  ac- 
companied by  a  wound.  These  reflections,  which  the  bad  success  of 
those  cruel  fractures  has  suggested,  have  caused  me  to  present  to  the 
public,  in  1750,  a  method  for  amputating  the  thigh  at  the  hip,  and 
that  to  try  and  snatch  the  wounded  from  inevitable  death." — RAVANTON, 
Chir.  d'Armce,  p.  324. 


COMPOUND   FRACTURE   OF    THE    EXTREMITIES.          257 

cases,  that  we  ought  not  to  keep  up  extension  in  their  treat- 
ment, except  in  a  very  modified  degree.  If  we  do  so — if  we 
drag  and  haul  at  the  bone,  as  I  have  often  seen  done — what 
is  the  result?  A  large  hiatus  exists,  void  of  organizable 
material  for  forming  the  bone;  the  parts  active  in  repair 
are  drawn  far  apart,  and  a  tax  is  made  on  the  reparative 
process,  which  I  will  not  go  the  length  of  denying  may, 
under  the  most  favorable  circumstances,  be  brought  about; 
but  which  I  am  fully  certain  never  could  be  accomplished 
with  us.  In  many  cases  it  would,  to  my  mind,  be  better 
practice — i.e.  it  would  afford  better  results  in  saving  life  and 
liuib — rather  to  approximate  than  draw  apart  the  fractured 
e"nds  in  such  cases.  Allow  the  ends  of  the  bones  to  be 
drawn  by  the  muscles  toward  one  another,  having  first  re- 
moved the  sequestra,  and  attend  merely  to  keeping  the 
limb  as  straight  as  possible ;  or,  in  other  words,  do  not  be 
troubled  with  the  displacement  as  to  the  length,  but  only  as 
to  the  thickness  of  the  bone,  and  I  believe  our  chance  of 
success  would  be  improved.  Deformity  we  would  unques- 
tionably have — shortening  and  twisting,  and  a  limb  of  which 
I,  for  one,  by  no  means  recommend  the  keeping;  but  if  we 
must  save  the  extremity,  if  its  retention  is  to  be  the  test  of 
good  management,  then  I  think  our  hope  must  be  in  some 
step  like  the  foregoing. 

There  are  rare  instances  of  compound  fracture,  which 
seldom  present  themselves  now-a-days,  in  which  the  bone  is 
but  little  comminuted,  and  which  demand  a  different  con- 
sideration altogether  from  those  I  have  been  speaking  of. 
These  accidents  commonly  arise  from  the  contusion  of  a 
round  shot,  or  the  contact  of  a  piece  of  shell.  They  are, 
however,  so  very  rare  and  difficult  to  recognize  that  less 
harm  will  follow  from  the  same  line  of  practice  being  pur- 
sued with  them,  viz.,  that  of  immediate  amputation,  than  if, 
by  being  careful  about  such  rare  exceptions,  we  run  the  ex- 
treme hazard  of  sacrificing  the  majority  of  cases  which 
determine  the  rule. 

22* 


258  SURGERY   OF   THE   CRIMEAN    WAR. 

The  extensive  comminution  of  the  bone  by  a  conical  ball 
makes  the  indications  with  regard  to  the  management  of  the 
sequestra  more  evident  than  it  is  commonly  considered.  I 
do  not  think  we  paid  sufficient  attention  to  their  removal  in 
the  East.  It  may  be  true,  as  some  tell  us,  that  in  fractures 
with  the  old  ball,  it  was  desirable  to  meddle  as  little  as  pos- 
sible with  the  fragments  ;  but  this  is  the  teaching  of  only  a 
few.  However,  to  my  mind  the  question  assumes  a  totally 
different  light  when  viewed  by  the  pathological  results  we 
had  occasion  to  witness.  It  may  be  remarked,  before  pro- 
ceeding further,  that  it  is  impossible  not  to  recognize  the 
practical  nature  of  the  division  of  the  sequestra  made  by 
Dupuytren  into  primary,  secondary,  and  tertiary,  according 
to  their  degree  of  connection  with  the  parts,  and  this,  not- 
withstanding Esmarch's  assertions  to  the  contrary  ;  nor  can 
I  see  that  the  distinction  of  them,  proposed  by  the  latter, 
into  "  fracture-splinter"  and  "necrosed-splinter,"  makes  the 
thing  a  whit  clearer,  or  the  division  a  bit  more  useful ;  so 
that  in  the  following  remarks  I  will  adopt  the  old  division. 

The  longitudinal  sections  into  which  the  bone  is  split  are 
mostly  capable  of  consolidation,  except  at  points  where  their 
connection,  or  the  contusion  they  have  undergone,  places 
such  parts  of  them  in  the  position  of  tertiary  sequestra, 
which  will  exfoliate  at  some  undetermined  date.  These 
fragments  cannot  of  course  be  touched.  The  secondary 
splinters,  again,  or  those  loosely  connected — hanging  by  an 
extremity  or  by  an  edge  to  the  periosteum  or  to  the  tissues 
— are  commonly  very  numerous,  and  lie  by  their  detached 
parts  in  all  directions  to  the  axis  of  the  shaft.  The  primary 
sequestra,  or  those  wholly  separated  from  their  connection 
by  the  accident,  are,  in  fractures  from  the  conical  ball,  pe- 
culiarly numerous  and  destructive  in  their  action.  In  some 
cases  which  I  have  had  an  opportunity  of  examining,  these 
were  found  not  only  at  the  seat  of  fracture  placed  in  every 
possible  position  except  the  right  one,  but  also  driven  deeply 
into  the  soft  parts  on  the  side  of  the  limb  next  the  wound  of 


COMPOUND    FRACTURE    OF    THE    EXTREMITIES.  259 

exit — long,  sharp,  delicate  chips,  whose  presence  must  have 
been  the  cause  of  continued  suppuration,  of  low,  disorganiz- 
ing inflammatory  action  in  the  soft  tissues  and  bone,  which 
extended  its  ravages  to  limits  far  beyond  the  seat  of  injury. 
In  one  case  which  I  observed  in  camp,  where  partial  con- 
solidation had.  taken^place,  the  dead  sequestra  had  become 
so  involved  in  the  new  bone,  and  were  so  prominent,  so  irreg- 
ular, and  so  rough,  as  to  look  like  the  bristles  of  a  porcu- 
pine. When  to  these  considerations  we  add  the  chance  of 
other  foreign  bodies,  pieces  of  accoutrements  or  cloth,  re- 
maining between  the  broken  fragments,  and  the  ideas  sug- 
gjested  by  the  very  narrow  opening  to  the  surface  which  re- 
mains in  gunshot  wounds,  further  reasons  will  be  seen  for 
the  practice  which,  I  believe,  should  be  in  general  followed 
— namely,  enlarging  the  exit  wound,  (especially  if  it  be  the 
more  dependent,  or  if  it  be  a  conical  ball  which  has  occa- 
sioned it,)  extracting  all  loose  and  slightly-attached  frag- 
ments, and  keeping  the  aperture  open,  so  as  to  allow  of  the 
free  flow  of  the  pus. 

We  have  seen  that  the  severe  commotion  at  the  seat  of 
fracture  occasions  the  formation  of  that  large  "foyer"  which 
is  found  full  of  detached  and  dead  sequestra,  disorganized 
tissue,  and  acrid  pus,  and  which,  unless  it  be  got  rid  of,  con- 
tinues to  bathe  the  ends  of  the  shaft,  gives  rise  to  inflamma- 
tion in  the  medullary  membrane,  supplies  a  depot  of  absorp- 
tion for  the  uncollapsing  veins  of  the  bone,  and  finally  causes 
constitutional  poisoning.  Now,  as  a  ball  traversing  a  limb 
carries  the  fragments  it  detaches  toward  its  place  of  escape, 
it  is  evident  that  they  will  be  the  more  easily  got  hold  of  and 
removed  on  that  side  of  the  limb.  These  are  the  grounds 
on  which  the  practice,  advocated  above,  is  founded.  Unless 
such  a  step  as  is  indicated  be  had  recourse  to,  I  cannot  see 
how  it  is  possible,  except  in  very  rare  and  exceptional  cases, 
to  hope  for  the  cure  in  the  field  of  a  compound  fracture  of  a 
large  bone  by  a  conical  ball.  Dupuytren,  recognizing  the 
necessity  of  getting  quit  of  these  fragments,  recommends  the 


260  SURGERY    OF    THE    CRIMEAN    WAR. 

enlargement  of  both  orifices  to  an  extent  so  great  as  "that 
the  fingers,  introduced  by  either  opening,  should  pass  freely 
and  meet  without  impediment."*  This,  he  thought,  how- 
ever, should  be  avoided,  if  the  part  was  very  thick  and  mus- 
cular. The  proceeding  sketched  above  is  in  no  way  so 
severe  as  this,  and  would  be  probably  as  efficient  in  fulfilling 
the  end  in  view. 

All  surgeons  who  have  had  much  to  do  with  gunshot 
wounds  are  agreed  as  to  the  propriety  of  removing  those 
fragments  which  are  wholly  detached  ;  but  some  oppose  the 
removal  of  any  which  retain  the  least  attachment.  The  ob- 
jections which  have  been  advanced  against  the  extraction  of 
these  are,  chiefly,  that  they  assist  in  the  repair  of  the  breach, 
by  throwing  out  bone,  and  that  if  they  do  die,  they  will  be 
extruded  by  the  suppurative  process.  To  this  it  is  replied 
that,  if  these  fragments  are  at  all  extensively  attached,  their 
removal  is  never  contemplated,  but  that  if  they  are  con- 
nected only  by  a  border  or  an  end  to  the  shaft  or  the  peri- 
osteum, they  can  contribute  but  very  slightly  to  form  callus, 
and  will  almost  in  every  instance  die.  One  small  part  that 
is  covered  by  periosteum  may  generate  callus,  but  the  rest 
of  their  bulk  will  surely  perish,  and  give  rise  to  abscesses 
and  fistulous  openings ;  and  the  amount  of  irritation,  con- 
stitutional disturbance,  and  wasting  suppuration  which  they 
will  cause,  before  they  are  thrown  out  by  the  eliminative 
force  of  nature,  are  such  as  to  make  it  impossible  for  any 
but  those  whose  constitutions  are  the  strongest  and  most 
vigorous  to  withstand  it.  The  length  of  time  during  which 
these  spiculaa  keep  up  the  suppuration  and  retain  the  wounds 
open  not  only  render  the  patients  the  more  subject  to  pya3- 
mic  poisoning,  but,  what  is  of  some  consequence  in  military 
practice,  detain  the  men  longer  in  hospital ;  thus  encumber- 
ing the  wards,  and  keeping  the  patient  longer  exposed  to 


*  This  is  a  mere  repetition  of  the  opinion  of  Percy,  p.  188  of  his 
'   Manual/' 


COMPOUND  FRACTURE  OF  THE  EXTREMITIES.     261 

an  attack  of  those  fatal  forms  of  gangrene  which  prevail  in 
such  circumstances. 

It  is  needless  to  quote  authorities  to  show  how  practical 
experience  has  condemned  the  leaving  of  these  secondary 
sequestra  in  the  wound,  as  nearly  all  military  surgeons  are 
agreed  on  the  necessity  for  their  removal.  M.  Begin  thus 
formulizes  his  great  experience  in  a  communication  to  the 
Academy  :  "  I  do  not  know  any  precept  more  erroneous  and 
more  dangerous  in  surgery,  than  that  which  tells  us  to 
respect  and  retain  the  fragments  of  bone  partly  detached  in 
fractures.  These  fragments  almost  never  recover  their 
vitality,  nor  become  united  to  the  body  of  the  bone;"  and 
he  also  tells  us  in  another  place,  to  remove  not  only  "those 
pieces  which  are  entirely  detached,  but  also  all  those  which  are 
movable,  vacillating,  and  capable  of  being  extracted  without 
the  necessity  of  too  great  destruction."  M.  Hutin,  again, 
whose  position  in  the  Hotel  des  Invalides  gives  him  larger 
opportunities  of  observing  the  effects  of  sequestra  which 
have  been  left  unextracted  than  perhaps  any  surgeon  alive, 
says,  referring  to  his  recorded  cases:  "I  have  given  several 
observations,  taken  from  among  several  hundreds,  in 
order  to  show  that  the  portions  of  non-extracted  bone  end 
sooner  or  later  by  setting  up  eliminative  action,  which  is 
always  painful,  often  dangerous,  and  at  times  fatal.  I  have 
also  reported  other  cases  in  which  immediate  extraction  has 
been  followed  by  positive  cures,  comparatively  prompt. 
These  instances  confirm  the  principles  stated  above.  Like 
them,  or  even  more,  they  confirm  this  truth,  that  the  second- 
ary sequestra,  if  they  are  not  hurtful  at  the  time  when  the 
wound  is  received,  or  shortly  afterward,  become  so  almost 
to  a  certainty  at  last.  They  demonstrate  the  necessity  of 
removing  them."  Roux,  Baudens,  Dupuytren,  Guthrie,  and 
nearly  all  the  leading  surgeons  who  have  seen  many  gun- 
shot wounds,  repeat  the  same  thing.  I  had  many  times  the 
opportunity  of  seeing  that  these  partially-detached  fragments 
seldom  lie  in  the  axis  of  the  limb ;  so  that  if  they  did  come 


262  SURGERY   OF   THE    CRIMEAN    WAR. 

to  enter  into  the  new  bone,  they  would  be  more  a  hinderance 
than  an  assistance  to  its  assuming  its  functions,  not  only  from 
their  position,  but  also  from  their  interposing  between  the 
principal  sections  of  the  fractured  shaft,  and  preventing 
their  contact  and  union.  Their  partially-necrosed  condi- 
tion makes  them  very  liable  to  become  separated  by  a  future 
accident,  and  thus  to  be  free  to  act  more  powerfully  still  as 
foreign  bodies  in  the  economy.* 

Finally,  considering  the  question  in  all  its  bearings,  it 
must  appear  pretty  evident  that  the  removal  of  fragments 
must  tend  immensely  to  simplify  the  wounds  under  consider- 
ation, and  therefore,  that  not  only  should  all  spiculav  which 
are  entirely  detached  be  removed  as  soon  as  possible,  but 
that  the  same  line  of  practice  should  be  followed  with  regard 
to  those  which  are  so  far  detached  as  to  retain  but  slight 
connections,  and  whose  continued  vitality  must  be  doubtful; 
that  this  step  should  be  acomplished  by  enlarging  the  exit 
wound  ;  and  that  the  practice  is  especially  necessary  in  those 
cases  where  the  femur  is  implicated,  and  a  conical  ball  is 
the  wounding  cause. 

The  tertiary  fragments,  or  those  extensively  adherent, 
should  of  course  never  be  interfered  with.  Parts  of  these 
fragments  may  subsequently  exfoliate,  but  at  what  period 
this  may  occur  it  is  impossible  to  say.  They  may  not  appear 
for  months,  or  it  may  be  for  years.  Mr.  Curling  has  lately 
made  the  observation,  that  necrosed  portions  of  bone  in 
compound  fractures  are  longer  of  getting  loose  when  they 
are  connected  with  the  lower,  than  when  attached  to  the 
upper  part  of  the  shaft. 

Any  operative  interference  thought  necessary  for  the 
removal  of  sequestra  should  be  had  recourse  to  at  once, 
before  inflammation  has  come  on,  or  otherwise  it  will  be 


*  Esmarch  would  seem  to  disapprove  o'f  the  extraction  of  the 
secondary  spiculae,  but  the  tenor  of  his  further  remarks  tends  to 
show  the  necessity  for  their  removal. 


COMPOUND   FRACTURE   OF   THE    EXTREMITIES.          2G3 

more  difficult  for  the  surgeon,  and  not  only  more  painful, 
but  also  more  hurtful  to  the  patient. 

The  few  attempts  that  I  saw  in  the  East  to  resect  parts 
of  the  continuity  of  the  femur  were  certainly  most  unfortu- 
nate. Such  a  proceeding  is  manifestly  much  more  severe 
and  hazardous  than  that  I  have  referred  to  above.  The 
resections,  however,  did  remarkably  well  in  the  leg  and 
upper  extremity. 

In  the  classification  of  injuries  which  was  followed  in  the 
Crimea,  no  distinction,  unfortunately,  was  made  between 
fractures  in  the  uppep,  middle,  and  lower  part  of  the  femur, 
which  prevents  the  discussion  of  several  interesting  points. 

Although  making  every  endeavor,  I  have  only  been  able 
to  find  a  record  of  three  cases  in  which  recovery  followed 
a  compound  fracture  in  the  upper  third  of  the  femur  without 
amputation.  In  two  of  them  the  injury  was  occasioned  by 
round  balls,  and  the  comminution  was  slight.  In  the  third 
case  I  could  not  ascertain  what  species  of  ball  had  caused 
the  injury.  In  one  of  these  the  patient,  an  officer  of  the 
17th  Regiment,  was  in  the  highest  health  at  the  time  when 
he  was  wounded,  (8th  September,)  and  was  of  a  peculiarly 
buoyant  and  hopeful  temperament.  The  ball  entered  behind, 
and  was  removed  in  front,  a  little  below  the  great  trochan- 
ter,  by  Dr.  Ward  of  his  regiment.  This  patient  received  an 
amount  of  attention  which  it  would  have  been  quite  impos- 
sible to  bestow  in  the  field  under  ordinary  circumstances. 
He  had  a  mattress  constructed  so  that  his  wound  could  be 
dressed,  and  the  bedpan  introduced  without  disturbing  his 
limb.  He  was  wounded  at  a  time  when  the  comforts  of 
camp-life  were  little  behind  those  of  home;  and  yet  I  have 
been  informed  that  although  his  limb  was  in  a  very  good 
condition  when  he  left  for  England,  the  trouble  it  has  since 
given  him,  and  the  deformed  condition  in  which  it  remains, 
make  it  by  no  means  an  agreeable  appendage.  Another 
case  was  that  of  a  soldier  of  the  62d,  who  was  found  a  day 
or  two  after  being  wounded,  lying  in  the  dockyard  stores  of 


264  SURGERY   OF   THE    CRIMEAN    WAR. 

Sebastopol,  under  the  charge  of  the  Russian  surgeons.  He 
was  discovered  when  the  place  was  evacuated,  and  carried  to 
his  regimental  hospital,  where  he  recovered.  The  fracture 
in  this  case  was  in  the  lower  part  of  the  upper  third.  It 
had  been  occasioned  by  a  round  ball,  and  the  splintering 
was  not  great.  This  man,  however,  was  in  the  best  health 
when  hit.  He  had  just  joined  from  England,  and  his  injury 
was  comparatively  slight.  The  third  man  may  be  said  to 
have  had  his  limb  consolidated,  in  so  far  as  that  a  mass  of 
callus  was  thrown  out,  which  cemented  the  bone ;  but  he 
died  of  purulent  poisoning,  and  never  left  the  Crimea.  I 
could  not  find  out  whether  it  was  a  round  or  a  conical  ball 
which  caused  the  fracture  in  this  case.  I  know  that  the 
French  had  hardly  any  recoveries.  One  was,  however, 
presented  by  the  Baron  Larrey  to  the  Societie  de  Chirurgie 
last  May.  This  officer  had  been  wounded  in  the  upper 
third,  and  the  bone  had  consolidated.*  I  never  could  hear 
of  any  other  except  a  Russian,  whose  greatly  shortened  and 
deformed  limb  I  often  examined  at  Constantinople.  This 
man's  thigh  was  quite  firm,  and  had  been  allowed  to  unite 
almost  without  treatment.  There  were  probably  a  few 
other  cases,  but  they  did  not  fall  under  my  notice ;  although 
during  constant  wanderings  through  the  hospitals  in  front 
and  on  the  Bosphorus,  I  was  unremitting  in  my  inquiries 
after  such  cases.  I  am  certain,  however,  that  although  the 
instances  of  recoveries  were  rare,  they  were  yet  not  so  ex- 
ceptional as  recoveries  after  amputation  at  the  same  part, 
as  will  be  afterward  more  particularly  dwelt  upon ;  and 
thus  it  appears  that,  so  far  as  the  experience  of  this  war  is 
concerned,  we  must  conclude  that,  slight  as  the  chance  of 
saving  life  is  in  any  case,  it  is  still  our  part  to  attempt  con- 
solidation in  preference  to  amputation,  when  the  fracture  is 
in  the  upper  third  of  the  bone.  M.  Simon,  of  Geissen, 

*  The  records  of  the  Val  de  Grace  do  not  say  what  sort  of  ball 
caused  the  fracture  in  this  case. 


COMPOUND   FRACTURE   OF   THE   EXTREMITIES.  2G5 

draws  a  like  conclusion  from  a  review  of  all  the  reported 
cases  of  the  injury;  but  he  extends  the  doctrine  to  the 
middle  third,  in  which  I  cannot  agree  with  him,  for  reasons 
which  I  will  afterward  state.  In  the  Sleswick-Holstein 
war,  they  preferred  amputation  to  preservation  in  such 
cases.  M.  Hutin,  in  the  Invalides,  was  able  to  discover 
twenty-four  cases  of  recovery  after  compound  fracture  by 
gunshot  above  the  middle  of  the  thigh,  but  no  case  of 
recovery  after  amputation  in  the  same  part.  This  goes 
further  to  prove  the  position  maintained  above.  In  what- 
eyer  way  we  decide,  it  is  unfortunately  too  true  that  death 
will  most  commonly  follow ;  but  yet,  when  we  do  not  oper- 
ate, the  patient  may  live  in  comparative  comfort  for  several 
weeks,  while,  in  the  other  case,  he  has  to  undergo  a  very 
fearful  operation,  and  almost  certainly  dies  within  twenty 
days. 

From  the  construction  and  limited  range  of  the  official 
returns,  it  is  impossible  to  show  in  figures,  what  was,  how- 
ever, a  well-recognized  result  of  the  surgery  of  the  war,  that 
though  union  did  in  rare  cases  follow  compound  fractures  in 
the  middle  and  lower  third  of  the  thigh,  still  the  ultimate 
percentage  of  loss  was  greatly  less  when  primary  amputation 
had  been  performed  than  when  limbs  were  saved,  or  tried  to 
be  preserved,  or  removed  at  a  late  period.  When  we  take 
into  consideration  the  fact  so  well  brought  out  by  the  authors 
of  the  "  Compendium  de  Chirurgie  Pratique,"  and  partly 
given  in  the  note* — that  we  should,  on  the  one  side,  calcu- 

*  "If  we  take  100  wounded,"  says  the  author  of  the  article 
"  Plaies  d'armes  a  feu,"  "  all  of  whom  have  received  severe  injuries 
of  the  extremity,  necessitating  amputation,  and  operate  immediately 
— if,  on  the  other  hand,  we  take  another  hundred  in  the  same  condi- 
tion, and  wait  to  perform  secondary  amputation  on  those  who  survive 
the  primary  accidents,  and  then  compare  results — as  far  as  it  is  possible 
to  judge  from  observations  borrowed  from  militai*y  surgeons,  here  is 
what  follows  in  either  case.  Without,  hoping  in  the  first  case  for  a 
success  equal  to  that  of  which  S.  Cooper,  and  Larrey,  and  other  inil- 

23 


266  SURGERY   OF   THE   CRIMEAN    WAR. 

late  those  who  die  before  the  period  for  consecutive  amputa- 
tion comes  round,  as  well  as  those  who  do  not  recover  from 
it,  and  not  merely  those  who  die  after  being  submitted  to  the 
operation — then  the  force  of  the  teaching  which  inculcates 
primary  amputation  in  these  cases  becomes  much  greater. 
Besides,  as  the  cases  which  were  retained  for  trial  were 
always  those  in  which  the  amount  of  injury  was  least  severe, 
and  the  patients  those  most  adapted  for  recovery,  the  pre- 
sumption in  favor  of  early  amputation  is  the  more  decided. 
There  can  be  little  doubt  that  the  chance  of  obtaining  con- 
solidation is  greater  in  the  lower  than  in  the  middle  third, 
as  is  also  the  hope  of  recovery  from  amputation ;  so  that, 
taking  one  thing  with  another,  the  experience  of  this  war 
would  lead  to  the  conclusion,  that  when  the  thigh  is  frac- 
tured by  a  ball  in  the  upper  third,  it  should  be  saved,  but 
that  amputation  should  be  immediately  had  recourse  to  in 
cases  of  a  like  injury  occurring  in  the  middle  or  lower  thirds. 
Those  fractures  of  a  simple  description,  which  at  times 
present  themselves,  are  not  meant  to  be  included  in  this 
remark,  nor  is  it  to  be  understood  that,  under  more  auspi- 

itary  surgeons  speak,  we  may  reasonably  expect  that  the  fatality  will 
be  here  what  it  is  in  the  greater  part  of  other  amputations ;  that  is 
to  say,  that  it  will  not  pass  the  fourth  or  the  third  of  those  operated 
on.  In  the  second  case,  on  the  contrary,  if  we  admit  the  number  of 
Bilsguers,  who  was  so  decided  an  opponent  to  amputation,  we  must 
expect  to  see  the  half  of  the  wounded  succumb  to  the  primary  acci- 
dents, such  as  gangrene,  inflammation,  abscess,  etc. ;  50  patients 
in  the  100  will  thus  remain,  retaining  a  wound  which  will  call  for 
secondary  operation.  When,  then,  the  success  surpasses  all  expecta- 
tion, when  we  save  9  in  10  operated  on,  the  number  of  those  who 
survive  will  be  yet  less  than  if  we  followed  the  opposite  practice  ;  as, 
accepting  the  preceding  hypothesis  as  exact,  (and  we  think  we  have 
made  them  more  favorable  to  secondary  amputations  than  facts  coun- 
tenance,) there  remains  70  to  75  surviving  in  100  after  immediate 
amputation,  while  there  remains  45  or  more  after  consecutive  am- 
putation. We  also  hasten  to  add  that,  in  allowing  for  the  moment 
the  superiority  of  secondary  over  primary  amputation,  we  have  made 
an  exaggerated  concession,"  etc. 


COMPOUND   FRACTURE   OF   THE   EXTREMITIES.  267 

cious  circumstances  as  to  the  condition  of  the  patients  and 
the  means  of  treatment,  better  results  than  those  we  meet 
with  may  not  follow  the  preserving  of  the  limb.  In  fact, 
under  ordinary  circumstances,  recourse  should  always  be  had 
to  the  steps  I  before  spoke  of,  with  regard  to  the  removal  of 
spiculae  in  cases  of  fracture  of  the  lower  third,  and  then  try 
to  save  the  limb ;  but  in  a  like  injury  of  the  middle  third, 
the  rule  should  be  to  amputate. 

It  is  certainly  very  much  opposed  to  the  modern  ideas  of 
conservatism  to  condemn  limbs  without  a  trial,  and  I  am 
fu,lly  aware  how  difficult  it  is  to  become  persuaded  of  its 
necessity ;  but  the  unwilling  conversion  at  last  is  made, 
though  it  is  generally  gained  by  the  loss  of  several  lives. 
The  French  surgeons  in  the  East  fully  acknowledged  the 
hopelessness  of  these  cases ;  but  the  fatality  of  amputation 
was,  with  them,  little  behind  that  of  preservation.  This 
experience  is  as  old  as  the  history  of  war,  and  comes  re- 
peated in  renewed  accents  from  every  battle-field.  Military 
surgeons  are  almost  unanimous  upon  the  necessity  of  ampu- 
tating in  the  cases  specified,  and  most  civilians  who  have 
had  an  opportunity  of  seeing  much  of  these  accidents  have 
come  to  a  like  conclusion,  as  can  be  seen  by  the  tenor  of  the 
communications  to  the  Academy  by  the  first  surgeons  of 
France.  It  would  be  mere  waste  of  time  to  record  the 
strong  and  decided  verdicts  which  have  been  given  on  this 
point,  and  which  find  their  summing  up  in  the  words  of  one 
of  the  greatest  surgeons  of  any  age  or  country,  when  Pupuy- 
tren  says,  in  one  of  his  clinical  lessons:  "I  have  repeated  it 
often,  and  I  repeat  it  for  the  last  time,  after  the  facts  which 
I  have  observed,  chiefly  in  1814,  1815,  and  1830,  that  my 
opinion  upon  this  point  is  unshaken.  In  compound  frac- 
tures from  gunshot,  in  rejecting  amputation  we  lose  more 
lives  than  we  save  limbs."  The  sagacious  Hennen  indorses 
the  same  view  when  he  says :  "  I  am  well  convinced  the  sum 
of  human  misery  will  be  most  materially  lessened  by  permit- 
ting no  ambiguous  case  to  be  subjected  to  the  trial  of  pre- 


268  SURGERY   OF   THE   CRIMEAN    WAR. 

serving  the  limb."  Larrey,  Guthrie,  and  in  fact  all  the 
leading  military  surgeons  of  modern  times,  proclaim  the 
same  thing.  That  exceptions  must  sometimes  be  made,  is 
undoubted ;  but  still  they  are  only  exceptions,  and  rare  ones 
too.  Cases  of  compound  fracture  near  the  knee  peculiarly 
call  for  amputation,  if  the  bone  be  split  into  the  joint.* 

The  results  which  we  obtained  might  most  likely  have 
been  more  satisfactory  if  the  army  had  made  another  cam- 
paign. Our  bad  hygienic  condition  deprived  us  of  the  im- 
provements made  in  surgery  during  the  last  half  century. 

But,  even  in  those  exceptional  cases  which  result  in  con- 
solidation, the  condition  of  the  limb  is  not  encouraging. 
To  this  Guthrie  bears  strong  testimony  from  his  experience 

*  I  cannot  avoid  giving  the  following  remarks  of  M.  Begin:  "All 
military  surgeons  have  begun  by  wishing  to  preserve,  but,  as  their 
experience  increased  and  their  observation  extended,  they  amputated 
more,  and  they  gain  the  conviction  that  they  are  right.  At  the  out- 
set of  my  career  I  amputated  less  than  I  did  toward  the  end  of  my 
service,  as  surgeon-in-chief  of  great  establishments.  There  are  cer- 
tain cases,  very  often  exaggerated,  of  wounded  who  pretend  to  have 
preserved  limbs  which  the  surgeon  wished  to  remove :  I  have  been 
present  very  often  at  the  miserable  death  of  persons  who  have  refused 
the  operation,  or  who,  they  thought,  would  avoid  it.  The  small  num- 
ber of  the  first,  who  boasted  loudly,  cannot  compensate  for  those 
much  more  numerous  of  the  second,  which  caused  me  much  sorrow. 
And  besides,  how  often  are  these  preserved  members  not  a  pitiable 
burden  for  those  who  carry  them  ?  Ask  the  surgeon  of  the  Invalides 
if  he  is  not  asked  every  year  by  some  of  these  old  soldiers  to  deliver 
them  from  the  parts  which  are  an  annoyance  to  them,  and  which 
cause  them  inconvenience  and  incessant  pain.  I  think  it  a  great  mis- 
fortune that  our  military  surgeons  should  allow  themselves  to  be 
seduced  by  some  of  the  assertions  which  you  have  heard ;  this  for- 
getfulness  of  the  experience  of  their  most  illustrious  predecessors 
will  cause  certainly  the  loss  of  many  men,  which  the  art,  exercised 
with  a  more  reasonable  energy,  might  save."  "I  know  that  there 
exist  examples  of  recoveries  with  shortening,  and  fistulas  remaining 
for  years,"  says  Baudens;  "but  to  save  two  with  fractured  femurs, 
and  to  heal  them  imperfectly,  we  will  lose  thirty,  of  whom  fifteen  or 
more  would  have  survived  immediate  amputation." 


COMPOUND  FRACTURE  OP  THE  EXTREMITIES.     269 

after  Toulouse.  M.  Ribes,  as  is  well  known,  failed  to  find 
a  single  case  of  recovery,  either  after  compound  fracture  or 
amputation  in  the  middle  of  the  femur,  among  4000  cases 
which  he  examined  in  the  Invalides  at  the  period  of  his  first 
visit ;  but  during  subsequent  years  he  saw  seven  cases  there 
of  "cured"  compound  fractures,  five  of  whom  died  after 
many  years  of  great  suffering  arising  from  the  injury,  and 
the  other  two  he  lost  sight  of,  as  they  left  the  institution  ; 
but  when  last  seen  they  were  in  a  grievous  plight,  and  he 
says,  "it  is  probable  that  these  two  soldiers  died  from  the 
"effects  of  their  accidents,  and  if  they  did  not,  their  condition 
must  be  greatly  still  more  wretched."  In  all  the  seven  cases 
there  was  union  certainly,  but  it  was  attended  by  much  de- 
formity, necrosis,  and  caries.  Long  years  of  suffering,  con- 
stant abscesses,  exfoliations,  atrophy,  sensitiveness  to  the 
slightest  atmospheric  change,  shortening  and  deformity,  the 
development  of  phthisis,  if  it  be  in  the  constitution, — these 
are  among  the  results  of  a  "cure"  of  a  compound  fracture 
by  gunshot  in  the  middle  of  the  thigh.* 

*  In  the  Punjab,  ami  oilier  Indian  campaigns,  I  have  been  able 
to  find  the  details  of  24  cases  of  compound  fracture  of  the  thigh, 
(parts  not  specified,)  in  which  the  attempt  at  saving  the  limb  was 
made.  Of  these,  14  died  very  soon;  but  of  the  ultimate  state  of  the 
remaining  10,  or  whether  they  continue  to  survive,  I  find  no  notice. 
Dupuytren,  in  1880,  lost  7  out  of  13  cases  treated  by  him.  Mal- 
gaigne,  in  1848,  lost  3  out  of  5,  all  being  select  cases,  and  those  not 
adapted  for  immediate  amputation.  Baudens,  in  one  series  of  (iO, 
which  he  mentions  in  his  book,  amputated  15  immediately,  of  whom 
13  survived;  20  were  amputated  late,  of  whom  only  4  recovered. 
The  remaining  2o,  although  tried  "  avec  obstination"  to  be  saved,  all 
died  miserably  except  2,  who  retained  "a  deformed  member,  unfit  to 
fulfill  its  functions,"  and  which,  he  says,  they  would  willingly  part 
with.  "Taking  a  retrospective  view/'  says  Bell,  "we  see  in  true 
perspective  all  the  dangers  of  a  nine-months1  cure,  which  is  but  a 
weary  travel,  step  by  step,  betwixt  life  and  death.  In  this  view  we 
see  the  dangers  of  frequent  fevers,  uniting  diarrhoeas,  foul  and 

23* 


270  SURGERY    OF   THE   CRIMEAN   WAR. 

Finally,  then,  let  me  repeat  the  conclusion  ;  that  under 
circumstances  of  war  similar  to  those  which  occurred  in  the 
East,  we  ought  to  try  to  save  compound  comminuted  frac- 
tures of  the  thigh  when  situated  in  the  upper  third;  but 
that  immediate  amputation  should  be  had  recourse  to  in 
the  case  of  a  like  accident  occurring  in  the  middle  or  lower 
third. 

Many  of  the  fractures  of  the  leg-  were  so  severe  as  to  call 
for  early  amputation.  Severe  shell  or  round  shot  wounds 
seldom  leave  much  hope  of  saving  the  limb ;  but  in  a  large 
number,  however,  of  very  unpromising  cases,  the  leg  was 
preserved.  A  great  deal  was  done  in  the  leg  in  the  way  of 
removing  fragments.  Guthrie  says  they  can  be  extracted 
"to  almost  any  extent  and  number,'1  and  he  directs  us,  if 
necessary,  to  saw  off  irritating  parts  of  the  ends  of  the 
shafts.  If  one  bone  only  be  broken,  and  the  loss  of  sub- 
stance in  it  is  not  great,  the  case  will  be  the  more  promising, 
as  the  unbroken  bone  keeps  the  fractured  one  steady  and  the 
soft  parts  in  place.  It  is  when  a  scale  of  the  bone,  however 
thin,  remains,  as  we  occasionally  see  it  in  shell  wounds,  that 
the  best  results  in  the  way  of  cure  are  obtained.  Such  was 
the  case  in  a  most  successful  instance  of  repair,  in  a  man  of 
the  20th  Regiment,  under  the  care  of  my  friend  Dr.  Howard 
of  that  regiment.  I  relate  it,  because  it  may  be  looked  on 
as  an  example  of  a  class  of  cases  which  were  not  uncommon. 
A  piece  of  shell  struck  the  edge  of  the  left  tibia,  and  de- 
stroyed the  greater  part  of  the  thickness  of  its  shaft,  from 

gleety  sores :  some  dying  suddenly  of  gangrene,  some  wasted  by  the 
profuse  discharge  and  successive  suppurations,  new  incisions,  and 
unexpected  discharges  of  spoiled  bones :  we  see  those  who  recover 
halting  on  limbs  so  deformed  and  cumbersome  that  they  are  rather 
a  burden  than  a  help.  In  the  very  moment  that  we  hear  of  such  a 
cure,  we  know  how  much  the  patient  must  have  suffered,  and  how 
poorly  he  has  been  cured ;  and  we  can,  from  the  long  sufferings  of 
those  who  escape,  tell  but  too  truly  how  many  must  die." 


COMPOUND   FRACTURE   OP    THE   EXTREMITIES.          2?1 

below  the  tubercle  downward  for  about  three  and  a  half 
inches.  The  fragments  were  removed  at  the  time  of  the 
accident,  or  afterward,  as  they  became  loose ;  the  posterior 
shell  of  the  bone  being,  however,  entire,  was  carefully  pre- 
served. Four  months  afterward  this  patient  was  sent  to 
England  with  a  strong  and  useful  leg,  whose  only  change 
was  a  slight  bending  outward — a  condition  which  generally 
remains  in  these  instances.  This  case  was  just  such  a  one 
as  presents  the  best  hope  for  a  good  result.  I  by  no  means 
v  would  infer  that  some  most  excellent  recoveries  did  not  take 
place  when  resections  were  performed  of  pieces,  including 
whole  thickness  of  the  shaft  of  the  tibia ;  but  they  were  the 
much  more  rare,  and  infinitely  more  tedious  than  cases  like 
the  foregoing.  When  the  leg  is  fractured  low  down  near 
the  ankle  by  a  ball,  the  accident  is  much  more  grave  than 
when  it  takes  place  at  the  middle  of  the  limb.  I  have  ex- 
ceedingly seldom  seen  a  case  recover  in  which  the  tibia  was 
split  into  the  joint. 

The  free  anastomosis  which  exists  between  the  vessels  of 
the  upper  extremity,  the  large  supply  of  blood  which  they 
convey,  the  ready  development  of  a  compensating  circula- 
tion, the  less  drain  there  is  on  the  system  during  the  period 
of  suppuration,  and  the  less  call  there  is  for  the  patient  to 
retain  a  constrained  and  irksome  position  during  cure,  ren- 
der many  things  practical  in  compound  fractures  of  the 
upper  extremity  which  could  never  be  attempted  in  like  in- 
juries of  the  lower  limb.  The  injury,  indeed,  would  need  to 
be  very  extensive  before  we  would  think  of  performing  am- 
putation at  an  early  period  in  gunshot  wounds  of  the  arm ; 
as,  unless  the  vessels  are  destroyed,  there  are  many  most 
dreadful  and  hopeless-looking  accidents  from  which  the  arm 
will  recover ;  and,  besides,  secondary  amputations  are  so 
successful,  and  resections  so  often  sufficient  to  fulfill  the 
necessary  indications,  that  primary  amputation  is  never  per- 
formed in  the  upper  extremity  except  under  the  most  des- 


272  SURGERY   OP   THE   CRIMEAN   WAR. 

perate  circumstances.*  Stromeyer  recommends  the  trunk 
to  be  made  the  splint  in  treating  these  cases,  so  as  to  do 
away  with  all  that  fear  of  motion  in  the  fragments  which 
exists  if  they  are  treated  in  the  usual  way.  Unfortunately, 
however,  as  pus  commonly  burrows,  and  has  to  be  evacu- 
ated on  the  inner  aspect  of  the  arm,  it  is  difficult  to  carry 
such  an  idea  into  practice.  Pirogoff,  it  appears,  was  so 
displeased  with  the  results  of  his  attempts  to  cure  fractures 
of  the  upper  extremity,  in  the  Caucasus,  that  he  was  dis- 
posed to  submit  them  all  to  amputation.  The  world  will 
learn  with  interest  whether  his  experience  in  Sebastopol  has 
not  been  more  favorable. 

The  results,  with  regard  to  fractures  of  the  forearm,  do 
not  tell  the  whole  truth,  as  there  is  no  provision  made  in  the 
returns  for  showing  double  injuries ;  many  cases  are  made 
to  appear  as  having  ended  fatally,  from  these  and  other 
comparatively  trivial  injuries,  which  were,  in  truth,  the  re- 
sult of  a  complication  of  accidents,  of  which  this  was  the 
one  chosen  for  registration.  I  have  known  this  occur  often. 
Fractures  of  the  forearm,  when  not  combined  with  other  in- 
juries, turned  out  most  satisfactorily.  Hardly  a  case  came 
under  my  notice  which  did  not  do  well,  even  although  the 
comminution  of  the  bones  was  very  considerable. 

As  to  the  treatment  of  compound  fractures  little  remains 
to  be  said  beyond  what  has  been  already  hinted  at,  or  what 
is  commonly  pursued.  Perfect  fixture — a  fixture  so  well  se- 
cured as,  if  possible,  never  to  be  disturbed  during  the  pro- 

*  The  following  is  a  curious  instance  of  recovery  from  a  most 
hopeless-looking  injury.  It  is  related  in  one  of  the  Indian  regi- 
mental reports  in  the  War-office.  A  soldier  received,  in  the  Khyber 
pass,  a  sword-cut  which  divided  his  arm,  bone  and  all,  with  the 
exception  of  the  vessels  and  nerves,  and  the  muscles  on  the  inner 
side.  He  also  received  another  wound,  which  laid  bare  the  spine 
and  ribs  ;  yet  he  recovered,  the  bone  of  the  arm  uniting.  He  died 
afterward  of  another  accident.  Two  somewhat  similar  instances,  one 
from  Percy,  are  related  by  Ballingall,  pp.  343-4. 


COMPOUND   FRACTURE   OF   THE   EXTREMITIES.  273  . 

cess  of  consolidation  ;  plenty  of  fresh  air ;  the  free  discharge 
of  pus  obtained  by  judicious  and  early  incisions  and  by  posi- 
tion, and  not  by  manipulations  of  the  injured  part ;  and  the 
administration  of  tonics  and  nourishment,  but  as  little  strong 
stimulation  with  brandy  and  wine  as  possible, — these  com- 
prise all  the  chief  points  in  the  treatment. 

Purulent  absorption  has  been  the  cause  of  death  in  the 
vast  majority  of  those  compound  fractures  which  ended 
fatally.  Pus,  occupying  both  the  chief  veins  and  the  inter- 
,stices  of  the  bone,  was  commonly  found,  and  purulent  de- 
posits in  the  lungs  very  generally  existed.  I  do  not  think, 
looking  at  the  question  as  a  whole,  that  our  experience 
would  lead  us  to  subscribe  to  Yelpeau's  doctrine,  that  "  pu- 
rulent absorption  is  more  common  among  those  who  undergo 
amputation  than  among  those  who  have  severe  suppurations 
and  preserve  their  limbs."  Hectic,  the  renewal  of  old  en- 
teric disease,  and  cholera  carried  off  many  of  our  patients 
under  treatment  for  compound  fracture. 

The  results  which  followed  the  treatment  of  gunshot 
wounds  of  the  hand  and  foot  were  very  satisfactory  in  most 
instances.  Balls  perforating  either  created  a  great  deal  of 
destruction,  but  the  rapair  was  not  slow.  "  The  talent  of 
preserving"  was  well  shown  in  the  Crimean  hospitals  in 
these  instances,  and  in  general  the  results  rewarded  the  en- 
deavors made  to  save  the  member. 

It  is  remarkable  how  few  sequestra  separate  in  gunshot 
wounds  of  the  hand,  even  when  the  shattering  of  the  bones 
has  been  great.  The  extrusion  of  any  large  piece  of  bone 
seldom  occurred,  so  far  as  I  saw.  In  gunshot  wounds  per- 
forating the  foot,  the  most  marked  feature  was  the  great 
swelling  which  followed,  and  the  extreme  pain  which  this 
distentiou  generally  caused.  How  far  the  rapid  cures  ob- 
tained in  the  field  may  remain  permanent,  I  am  at  a  loss  to 
know ;  but  I  fear  that  not  a  few  of  the  cases  "  patched  up" 
and  sent  home  may  have  to  undergo  operation  at  a  subse- 
quent date. 


2T4  SURGERY   OF   THE   CRIMEAN    WAR. 

In  dealing  with  gunshot  injuries  so  severe  as  to  demand 
operation  in  the  field,  we  can  often  save  more  of  the  part  of 
the  hand  or  foot  than  usually  after  accidents  in  civil  life. 
The  soft  parts  are  seldom  so  much  destroyed,  in  proportion 
to  the  injury  inflicted  on  the  hard  tissues,  by  a  musket-ball  as 
by  a  wheel  of  machinery ;  and  thus  we  are  not  called  upon 
to  remove  so  much  of  the  member  in  order  to  secure  a  good 
covering  for  the  hard  tissues. 


CHAPTER   XI. 

GUNSHOT    WOUNDS   OF   JOINTS — EXCISION    OF   JOINTS,  ETC. 

Gunshot  wounds  of  joints  form  a  group  of  cases  most 
interesting  to  the  surgeon.  "  As  for  a  wounded  joint,"  says 
John  Bell  in  his  treatise  on  gunshot  wounds,  "  we  may  take 
the  united  experience  of  all  surgeons,  which  has  established 
this  as  the  true  prognostic,  that  wounds  of  the  joints  are 
mortal"  Without,  however,  being  so  sweeping  in  the  con- 
demnation of  such  cases,  it  must  be  affirmed  that  no  class 
of  gunshot  injuries  prove  more  uncertain  in  their  results,  or 
are  more  commonly  followed  by  disastrous  consequences. 

The  gravity  of  gunshot  wounds  of  the  joints  will  depend 
chiefly  on  the  size  and  construction  of  the  articulation,  the 
extent  of  the  injury,  and  the  attention  received  by  the  pa- 
tient shortly  after  being  wounded — especially  the  means  of 
treatment  being  at  hand,  and  not  necessitating  long  trans- 
port.* As  a  very  grave  amount  of  destruction  may  be  iii- 

*  Mr.  Alcock  classes  cases  of  wounded  joints,  with  reference  to 
their  results,  under  three  heads  :  those  treated  under  1.  "Favorable 
circumstances, — Cases  admitted  into  a  large,  well-organized,  and  com- 
modious hospital  an  hour  or  two  after  the  injury  was  inflicted,  and 
there  treated  to  the  end,  under  the  same  medical  superintendence, 
and  with  all  essential  means  for  good  treatment.  2.  Partially  un- 
favorable circumstance*. — Cases  not  immediately  received  into  a  well- 
organized  hospital,  subjected  to  some  leagues  of  transport,  or  passing 
part  of  the  first  period  in  a  field  hospital  with  deficient  means,  or 
received  into  a  permanent  hospital  with  lax  discipline.  3.  Cases 
treated  under  unfavorable  circumstances,  or  those  admitted  into 
crowded  hospitals  with  epidemics  prevailing,  means  either  personal 
or  material  not  fully  adequate;  with  cases  of  wounds  inflicted  after 

(275) 


276  SURGERY    OF    THE    CRIMEAN    WAR. 

flicted  on  the  articulating  extremities  of  the  bones  without 
much  external  appearance  of  such  mischief,  we  are  often 
deceived  in  our  early  examination  of  these  cases  ;  and  this 
is  one  reason  for  delaying  the  adoption  of  decided  measures 
though  delay  so  frequently  proves  fatal. 

The  wound  of  a  ginglymoid  articulation  is,  as  a  general 
rule,  more  severe  than  that  of  a  ball-and-socket  joint, 
chiefly  from  its  more  complex  structure.  Larrey  noticed 
how  often  tetanus  was  caused  by  wounds  of  these  joints, 
and  every  surgeon  can  testify  to  the  extremely  severe  symp- 
toms which  follow  their  injury. 

Although  it  is  true  in  general  that  a  mere  fissure  extend- 
ing into  a  joint  may  not  be  followed  by  serious  results,  still 
it  is  no  less  certain  that  even  such  apparently  trivial  acci- 
dents are  often  followed  by  the  most  disastrous  consequences. 

It  is  a  matter  of  much  moment  to  possess  a  decided  opin- 
ion upon  the  treatment  of  gunshot  wounds  of  the  joints,  as 
in  no  class  of  cases  is  prompt  action  so  much  called  for,  and 
none  in  which,  by  the  parade  of  a  few  successful  cases,  is  the 
mind  of  the  surgeon  more  apt  to  be  misled.  If,  on  seeing 
a  case,  we  were  able  to  decide  what  remedies  were  demanded 
for  its  management,  then  possibly  much  suffering  and  no  few 
lives  would  be  saved. 

Gunshot  wounds  of  the  neighborhood  of  joints  require 
much  attention,  not  only  from  the  fear  of  secondary  impli- 
cation of  the  articulation,  but  on  account  of  the  stiffness 
which  is  apt  to  ensue  in  it  from  long  disuse  during  the 
period  of  cure.  Artificial  motion  should  be  begun  early  in 
these  cases. 

a  reverse  in  the  field,  or  long  subjected  to  the  deficient  means,  dis- 
comforts, and  imperfect  discipline  of  temporary  or  field  hospitals, 
with  one  or  two  days'  subsequent  transport  to  the  permanent  hospital 
stations."  He  adds:  "  The  evidence  of  these  statistical  results 
(those  having  reference  to  the  above  points)  is  too  striking  to  leave 
any  doubt  whatever  as  to  the  influence  which  these  circumstances 
exercise,  totally  independent  of  the  constitution  of  the  patient  and 
the  degree  of  injury." 


GUNSHOT    WOUNDS   OF   JOINTS.  27 T 

The  hip  is  too  deeply  placed,  and  too  much  protected  by 
the  surrounding  parts  and  its  own  form,  to  be  often  pene- 
trated by  a  ball ;  but  when  it  is  implicated,  the  destruction 
is  commonly  so  great  as  to  render  operative  interference  in 
some  form  imperative.  Alcock  lost  three  out  of  four  cases 
in  which  this  accident  occurred,  and  in  the  fourth  case, 
"where  recovery  took  place,  the  joint  itself,  there  is  some 
reason  to  suspect,  was  but  remotely  affected."  Occasionally 
a  round  ball  becomes  impacted  in  the  head  of  the  femur, 
and  may  cause  only  a  partial  fracture  of  its  neck.  It  is  not 
easy  in  either  of  these  accidents,  however,  to  recognize  the 
injury  at  first,  as  no  sign  of  displacement  or  crepitation  may 
be  perceived.  This  is,  however,  rare ;  but  the  following  is 
one  case  of  this  description.  It  is  related  in  the  register  of 
the  Depot  Hospital,  at  Colaba,  in  the  archives  of  the  medi- 
cal department :  Alexander  M'Phail,  aged  33,  wounded 
at  Dubba,  24th  March,  1843,  by  a  match-lock  ball,  which 
entered  a  little  above  the  great  trochanter  of  the  right  limb 
anteriorly,  and  was  lost.  His  leg  became  powerless.  On 
coming  to  Colaba  on  the  2Gth  April,  he  did  not  complain 
of  much  pain,  except  when  the  joint  was  moved.  Slight 
fullness  over  the  hip  was  the  only  symptom  of  injury. 
Leeches  and  counter-irritation  were  employed,  and  he 
seemed  to'  get  better.  On  May  6th  he  was  attacked  with 
trismus,  and  died  on  the  9th.  The  ball  was  found  im- 
bedded in  the  head  of  the  femur,  which,  with  half  of  the 
brim  of  the  acetabulum,  was  shattered,  and  the  capsular 
ligament  formed  the  sac  of  an  abscess  which  contained  a 
considerable  quantity  of  pus  and  spiculre  of  bone.  The 
orifice  of  the  wound,  it  is  added,  had  closed  some  time  pre- 
vious to  death.*  Larrey  mentions  the  case  of  an  officer 

*  Preparation  2004,  in  the  museum  at  Fort  Pitt,  was,  I  believe, 
obtained  from  this  patient,  as  the  description  of  it  in  the  catalogue 
is  as  follows:  "A  match-lock  ball  firmly  lodged  in  the  head  of  (he 
femur.  It  entered  opposite  to  the  trochanter  major,  and 

24 


2Y8  SURGERY   OF    THE   CRIMEAN    WAR. 

wounded  in  Egypt,  who  received  a  ball  in  the  neck  of  the 
femur.  The  wound  closed,  and,  twenty  years  afterward,  on 
the  death  of  the  patient  from  disease  of  the  chest,  the  ball 
was  found  impacted  in  the  bone. 

The  knee  when  penetrated  by  gunshot  presents  an  injury 
of  the  gravest  description.  Taking  much  interest  in  cases 
of  this  description,  I  visited  every  one  I  could  hear  of  in 
camp,  and  can  aver  that  I  have  never  met  with  one  instance 
of  recovery  in  which  the  joint  was  distinctly  opened,  and  the 
bones  forming  it  much  injured  by  a  ball,  unless  the  limb 
was  removed ;  yet  the  returns  show  several  recoveries  after 
such  wounds,  some  of  which,  at  any  rate,  I  cannot  but  think 
are  founded  on  error.  I  have  conversed  with  many  surgeons 
of  large  experience  on  the  subject,  but  never  heard  of  any 
case  recovering  without  amputation,  in  which  the  diagnosis 
of  fracture  of  the  epiphysis  was  beyond  doubt;  yet  such 
cases  have  been  put  on  record.  I  remember  one  case, 
probably  included  among  the  recoveries,  in  which  a  ball 
passed  near  the  joint,  causing  some  effusion  and  swelling  in 
it,  with  no  constitutional  disturbance  whatever,  and  resulting 
in  the  man's  return  to  duty  within  a  fortnight,  but  which 
the  surgeon  in  charge  put  down  as  a  penetrating  wound, 
remarking  (as  he  well  might)  on  the  curious  immunity  from 
constitutional  or  severe  local  symptoms  which  h'ad  marked 
the  case. 

The  following  is  a  very  interesting  case,  and  certainly 
one  of  the  most  difficult  to  explain  of  any  with  which  I  am 
acquainted.  I  never  saw  the  patient,  but  the  details  have 
been  kindly  sent  me  by  Deputy-Inspector  Taylor,  from 
Chatham:  "Private  George  Hayes,  aged  31,  47th  Regi- 
ment, was  wounded  at  the  Alma  by  a  grape-shot,  which 
entered  on  the  outer  side  of  the  ligamentum  patella,  and 

through  the  brim  of  the  acetabulum.  The  wound  in  the  skin  soon 
cicatrized,  but  the  patient  died  of  tetanus  six  weeks  after  the  receipt 
of  the  injury." 


GUNSHOT   WOUNDS   OF   JOINTS.  279 

passed  upward  through  the  knee-joint,  shattering  the  patella 
in  its  course,  and  making  its  exit  at  the  anterior  aspect  of 
the  thigh  about  its  middle,  partially  fracturing  it.  The 
greater  portion  of  the  patella  was  removed  in  the  course  of 
treatment,  as  well  as  various  fragments  of  the  femur  (exfo- 
liations ?) ;  but  firm  union  of  the  latter,  as  well  as  anchylosis 
of  the  joint,  fortunately  took  place.  At  the  time  of  his  dis- 
charge he  could  sustain  his  weight  upon  the  limb,  and  could 
walk  about  without  crutches."  I  saw  another  case  very 
similar  to  this  at  Scutari,  in  1855.  In  this  instance,  the 
ball  had  struck  the  man  when  he  was  about  to  kneel,  and 
apparently  fractured  the  head  of  the  tibia.  The  ball  was 
removed  from  the  anterior  part  of  the  thigh.  Scarcely  any 
bad  symptom  followed,  except  that  the  joint  swelled,  was 
painful  to  the  touch,  and  ended  by  losing  part  of  its  motion. 
If  the  articulation  escaped  the  passage  of  the  ball,  the  case 
was  very  curious. 

The  round  ball  sometimes  penetrates  the  lower  end  of 
the  femur  or  the  head  of  the  tibia  without  causing  splinter- 
ing, or  opening  the  joint,  or  at  least  with  an  amount  of 
injury  to  the  capsule  which  is  very  slight ;  and  such  cases 
may  recover,  and  so  shake  our  conclusions  about  others  of  a 
less  anomalous  character.  Balls,  too,  may  pass  very  close 
to  the  capsule  and  yet  do  it  no  harm,  though  these  cases 
are  put  down  as  penetrating  or  perforating  wounds  of  the 
joint* 

It  is  undoubtedly  often  very  difficult  to  know  whether  the 
joint  has  been  opened  or  not,  particularly  if  the  ball  is  a 

*  Alcock  thinks  that  if  a  ball  do  not  absolutely  project  within  the 
articulation,  or  if  the  foreign  body  be  smooth,  and  not  project  much 
beyond  the  articulating  surface,  the  limb  may  be  saved.  Inde- 
pendently of  the  fact  that  the  cases  are  infinitely  rare  in  which  a 
ball — especially  a  conical  one — can  thus  penetrate,  without  causing 
grave  and  irremediable  fracture  of  the  bones  entering  into  the  artic- 
ulation, it  is  not  at  nil  consistent  with  my  observation  that  Mich 
cases  can  be  saved.  One  case  mentioned  in  the  text  illustrates  this. 


280  SURGERY   OF    THE    CRIMEAN    WAR. 

small  one,  as  was  the  case  in  one  instance  afterward  men- 
tioned;  and  it  very  often  occurs  that  the  missile  has  run 
superficially  under  the  integuments,  or  coursed  round  the 
bones,  when  it  appears  to  have  passed  through  the  articula- 
tion. It  is  to  be  remembered,  also,  that  the  swelling  of  the 
joint  may  be  merely  the  result  of  a  bruise,  or  of  the  exten- 
sion from  the  neighborhood  of  the  inflammation  which  has 
been  caused  there  by  injury,  and  is  thus  no  sign  of  direct 
wound  of  the  joint. 

Another  point  whicti  renders  these  injuries  difficult  of 
recognition  when  the  bones  are  not  much  implicated,  is  the 
length  of  time  which  may  intervene  before  the  appearance 
of  severe  symptoms.  A  week  may  pass,  and  yet  both  the 
local  and  constitutional  symptoms  may  be  very  slight. 
Sooner  or  later,  however,  the  well-known  signs  of  joint- 
injury  are  set  up,  sometimes  with  great  rapidity  and 
severity. 

It  is  not  difficult  to  understand  the  peculiar  progress  and 
fatal  results  of  gunshot  wounds  of  the  knee,  when  we  con- 
sider how  sensitive  to  injury  are  shut  cavities  when  inclosed 
by  such  a  delicate  membrane  as  the  synovial  lining  of  the 
knee,  and  how  feelingly  such  cavities  resent  the  introduction 
of  air  within  them ;  how  rapidly  they  degenerate  under  the 
effects  of  this  air;  what  a  mass  of  closely-compacted  tissues 
become  implicated  when  disease  is  set  up  in  such  an  articu- 
lation ;  how  it  is  that  bone,  ligament,  and  soft  parts  partici- 
pate in  the  injury;  how  wide  the  bony  expanse  is  which 
enters  into  the  formation  of  the  joint;  and  what  a  large 
surface  is  presented  for  purulent  absorption  and  transmitting 
inflammation,  as  well  as  how  difficult  it  is  for  foreign  bodies 
or  morbid  secretions  to  obtain  free  exit.  These  are  the  chief 
causes  why  the  injuries  under  consideration  are  so  often  fol- 
lowed by  dangerous  and  fatal  results.  In  civil  life,  wounds 
opening  the  joint  are  commonly  caused  by  cutting  instru- 
ments. Foreign  bodies  are  seldom  introduced,  and  the  bones 
entering  into  the  articulation  are  little  if  at  all  injured. 


GUNSHOT   WOUNDS   OF   JOINTS.  281 

The  wound,  being  carefully  closed,  often  adheres,  and  by  ap- 
propriate treatment  little  mischief  may  follow.  But  if  a 
ball  be  the  wounding  agent,  foreign  bodies  are  almost  sure 
to  be  introduced  from  without,  or  created  within  by  the 
splinters.  The  ball's  track  must  suppurate  before  it  closes, 
and  it  cannot  be  shut  up  and  retained  without  the  hazard 
of  pus  accumulating  in  the  cavity  ;  air  thus  gets  admission, 
and  works  destruction.  Foreign  bodies  cannot  be  extracted 
by  so  small  an  opening  from  a  cavity  of  such  a  construction  : 
and  thus  these  gunshot  wounds  of  the  joint,  though  often 
apparently  very  trivial  injuries,  become  the  most  serious 
almost  of  any  which  can  be  presented  to  us. 

The  primary  dangers  of  these  wounds  are  not  great.  It 
is  in  those  which  are  set  up  afterward  that  the  chief  hazard 
exists.  The  long  and  wasting  suppuration,  the  tedious  and 
dangerous  abscesses,  and  the  purulent  poisoning  are  the 
principal  sources  of  alarm.  These  abscesses  are  most  curious 
occurrences  in  knee  cases.  They  appear  almost  invariably 
among  the  muscles  of  the  thigh  ;  and  while  they  may  remain 
long  unnoticed,  they  give  rise  to  the  utmost  trouble  and 
danger.  They  burrow  along  the  bone,  often  stripping  it  of 
its  covering,  and  yet  are  seldom  apparently  in  connection 
with  the  joint.  The  escape  of  some  small  amount  of  the 
acrid  secretions  into  the  superficial  or  deep  cellular  mem- 
brane sets  up  renewed  inflammation  and  suppuration  there, 
and  thus  abscesses  form  whose  connection  with  the  original 
depot  it  is  difficult  to  trace.  These  collections  almost  always 
occur  in  the  thigh  in-preference  to  the  leg.  At  a  late  period 
of  the  case,  the  joint  puts  on  all  the  appearances  of  white 
swelling — an  observation  first  made  by  Dr.  John  Thomson. 

Military  surgeons  of  all  times  have  recognized  the  neces- 
sity of  removing  the  limb  early  in  these  cases  when  the 
articulating  ends  of  the  bones  have  been  fractured  by  a  ball, 
and  the  experience  of  the  late  war  fully  bears  out  the  prac- 
tice. French  and  English  surgeons  were,  I  think,  agreed  on 
this  in  the  Crimea.  In  December,  1854,  I  saw  upwards  of 


282  SURGERY   OF    THE   CRIMEAN   WAR. 

forty  cases  in  the  French  hospitals,  and  all  died  except  those 
primarly  amputated.  I  have  heard  incidentally  of  one  case 
occurring  in  their  army  which  recovered,  but  have  failed  to 
learn  its  details.*  It  is  certainly  very  disheartening,  as  well  as 
humiliating  to  professional  pride,  to  think  that  we  cannot  save 
such  cases  without  amputation.  The  very  small  amount  of 
visible  destruction  which  is  so  often  present ;  the  slight  com- 
plaint of  pain  or  appearance  of  disturbance  which  frequently 
exists  at  the  period  when  the  limb  ought  to  be  removed  in 
order  to  insure  success ;  the  very  pardonable  unwillingness 
of  the  patient,  especially  if  he  be  an  officer,  to  submit  to  so 
dreadful  an  alternative,  where  there  is,  to  him,  so  little 
apparent  danger, — all  render  difficult  the  adoption  of  those* 
measures  which  a  dire  experience  has  shown  to  be  necessary, 
for  that  amputation  is  our  only  resource  all  are  agreed. 

Guthrie  has  seen  no  case  recover  in  which  the  limb  was 
not  removed.  Larrey  reports  some,  but  they  were  instances 
of  slight  injury.  Esmarch,  from  the  fields  of  Sleswick- 
Holstein,  says :  "All  gunshot  injuries  of  the  knee-joint,  in 
which  the  epiphysis  of  the  femur  or  tibia  has  been  affected, 

*  In  the  Indian  Reports  I  have  been  able  to  find  the  particulars  of 
nine  cases  in  which  the  knee  was  penetrated,  but  the  injury  was  ap- 
parently so  slight  as  to  lead  the  attendants  to  try  to  save  the  limb. 
Every  one  died.  Alcock  has  stated  the  proportion  of  cases  in  which 
the  articulations  are  wounded,  to  other  gunshot  wounds,  as  between 
4  and  5  per  cent.,  nearly  one-half  of  which  were  of  the  knee.  Of  05 
cases  in  which  an  articulation  was  primarily  affected,  33  recovered, 
21  with  loss  of  a  limb,  32  died,  18  without  amputation.  "It  is  quite 
evident,"  he  adds,  "  that  if  the  18  cases  of  death  without  amputation, 
and  the  14  cases  of  subsequent  amputations,  (assuming  them  to  be 
unfavorable  causes  for  treatment  in  the  first  instance,)  instead  of 
being  treated,  had  immediately  been  amputated,  we  should  then  have 
had  for  result,  not  a  loss  of  25,  but  of  one-third,  which  is  the  loss 
from  primary  amputation.  Two-thirds,  therefore,  or  16  out  of  the 
25,  would  have  been  saved."  Of  35  cases  in  which  the  knee  was 
more  or  less  implicated,  22  lost  their  lives,  and  of  the  remainder,  8 
lost  their  logs.  "After  such  results,  it  is  little  to  sny  that  the  5  who 
recovered  preserved  good  and  useful  limbs." 


GUNSHOT   WOUNDS   OF   JOINTS.  283 

demand  immediate  amputation  of  the  thigh.  It  is  a  rule 
of  deplorable  necessity  already  given  by  the  best  authorities, 
and  which  our  experience  fully  confirms." 

I  have  often  contemplated  the  laying  of  the  articulation 
freely  open  at  an  early  period  in  these  cases,  so  as  to  permit 
of  the  extraction  of  all  foreign  bodies,  and  the  free  escape 
of  the  pus  which  must  afterward  be  formed,  the  retention  of 
which  is  undoubtedly  one  great  source  of  danger.  This 
might  be  attempted  even  although  it  were  necessary  to  lay 
the  whole  front  of  the  joint  open  by  an  incision  similar  to 
that  for  excision.*  The  joint  has  been  frequently  widely 
laid  open  by  cutting  instruments,  both  primarily  and  for  dis- 
ease, and  most  satisfactory  cures  have  been  obtained. f 

If,  however,  the  attempt  is  to  be  made  to  save  the  limb, 
the  most  rigid  antiphlogistic  treatment  must  be  followed. 
Local  bleeding  by  leeches,  and  the  application  of  cold  ;  the 
avoidance  of  all  local  remedies  which  are  of  a  relaxing 
nature ;  the  perfect  fixture  of  the  articulation,  and  the  ab- 
sence of  all  pressure;  as  well  as  the  early  evacuation,  by  free 
incision,  of  abscesses,  and  of  matter  if  it  form  within  the 
joint, — these  are  the  leading  and  evident  indications  to  be 
followed.  Hectic,  with  its  common  accompaniment,  diar- 
rhoea, purulent  absorption,  with  secondary  implication  of 
internal  organs,  and  tetanus,  are  the  causes  which  most  com- 
monly bring  about  a  fatal  result. 

The  presence  of  the  articular  cartilages  would  be  of  little 
moment,  as  they  soon  disappear;  and  if  the  bones  were  kept 
in  close  contact,  firmly  fixed,  and  all  discharges  allowed 
freely  to  escape,  there  is  no  reason  why  most  favorable 
results  might  not  be  obtained.  Such  a  step  is  in  no  way  so 

*  At  the  time  the  above  was  first  written,  I  had  not  seen  Stro- 
meyer's  book,  and  did  not  know  that  the  same  idea  had  occurred  to 
him,  or  that,  in  the  only  case  in  which  he  had  practiced  it,  the 
results  had  been  most  encouraging. 

f  See  especially  a  paper,  by  Mr.  Gay,  in  the  Lancet  for  October  -•">, 
1 860, 


284  SURGERY   OF   THE    CRIMEAN   WAR. 

severe  as  excision  of  the  joint,  and  yet  how  successful  has 
this  been !  The  great  sources  of  irritation  and  danger  would 
be  done  away  with,  and  if  we  had  a  healthy  patient  to  deal 
with,  I  cannot  see  why  we  should  fail. 

If  amputation  is  thought  of,  the  sooner  it  is  undertaken 
the  better,  as  when  the  operation  is  performed  late,  after 
inflammation  and  suppuration  have  been  for  some  time 
present,  the  results  are  very  unfavorable.  The  joint,  when 
opened,  presents  most  of  the  characteristics  of  chronic  dis- 
ease, plus  the  immediate  injury  to  the  bone  —  cartilages 
eroded,  synovial  membranes  degenerated,  and  the  products 
of  inflammation  effused  into  the  cavity. 

In  those  cases  which  are  occasionally  saved,  the  cure  is 
very  slow  and  very  unsatisfactory.*  They  occur  only  in 

*  Alcock  says,  with  regard  to  the  boasted  cures  after  injured  joints  : 
"  By  a  limb  saved  I  do  not  mean  one  with  the  wounds  healed,  having 
nevertheless  the  extremity  contracted,  bent,  motionless,  or  otherwise 
useless.  Cases,  by  a  loose  kind  of  phraseology,  are  often  termed 
'  limbs  saved.'  The  object  of  saving  a  limb  is  that  it  may  be  useful. 
If  this  is  not  the  result  the  member  by  merely  hanging  to  the  body 
of  the  patient  is  lost  in  my  estimation  as  truly  as  if  amputated,  but 
with  the  additional  circumstances  of  being  converted  into  a  source  of 
misery  to  the  sufferer,  an  impediment  to  the  free  motion  of  the  rest 
of  the  body,  and  often  a  cause  of  irremediable  bad  health.  Such 
cases  I  hold  to  be  among  the  worst  specimens  of  bad  and  injudicious 
surgery."  It  is  much  to  be  regretted  that  surgeons  cling  so  much  to 
a  few  cases  of  recovery,  and  shut  their  eyes  to  the  vast  mass  of  in- 
stances in  which  the  attempt  to  save  life  and  limb  has  failed,  forget- 
ting that  "  Les  miracles  ne  peuveut  servir  de  base  a  aucun  jugement." 
John  Bell  puts  this  with  great  force  :  "Thinking  only  of  this  won- 
derful recovery,  the  surgeon  willingly  forsakes  an  uncomfortable 
rule  to  lay  hold  on  this  one  glimpse  of  hope,  while,  indeed,  if  he 
reasoned  fairly,  he  would  perceive  that  the  exception  should  be  lost 
in  the  fullness  of  the  general  rule,  and  not  the  general  rule  disturbed 
by  the  exception."  Alcjck,  too,  says:  "In  the  class  of  injuries 
under  consideration,  this  danger  is  most  especially  evident.  Many 
are  the  extraordinary  and  most  unlooked-for  successes  attending  the 
treatment  of  forlorn  cases  of  injured  joints.  Were  general  rules  ov 
principles  of  treatment  to  be  founded  on  these  cases,  which  are  but 


GUNSHOT    WOUNDS   OP   JOINTS.  285 

those  instances  in  which  the  bones  have  been  slightly  injured 
and  the  patients  possessed  of  a  first-rate  unimpaired  consti- 
tution, and  when  the  means  of  treatment  are  of  the  most 
perfect  description. 

The  particulars  of  cases  in  which  the  knee-joint  has  been 
penetrated  by  balls  are  so  similar,  that  I  will  only  give  a 
few  in  detail.  The  first  case  was  under  my  immediate 
notice,  and  from  its  presenting  what  might  have  been  con- 
sidered the  most  favorable  features  for  conservatism,  it  gave 
me  much  interest.  An  officer  of  the  63d  Regiment,  aged 
19  years,  was  accidently  wounded  by  his  own  revolver  during 
the  reconnoisance  in  force  at  Kinburn,  on  the  21st  October. 
He  was  half  reclining  on  the  ground  at  the  time  of  the  acci- 
dent, his  left  leg  stretched,  and  his  right  knee  half  bent. 
His  pistol  was  in  his  right  hand,  and  close  to  his  limb.  The 
muzzle  was  directed  downward,  and  obliquely  inward,  toward 
the  middle  line  of  the  body.  The  ball,  a  small  conical  one, 
weighing  four  drachms,  entered  at  the  outer  and  superior 
surface  of  the  lower  third  of  the  right  thigh,  about  three 
inches  above  the  border  of  the  patella,  and  lodged.  The 
wound  appeared  to  lead  into  the  cavity  of  the  joint,  and  an 
indistinct  grating  was  said  to  have  been  communicated  to 
the  hand  on  moving  the  patella  from  side  to  side.  Some 
bloody  greasy  fluid  escaped  from  the  wound.  On  the 
patient's  coining  into  camp,  a  few  hours  afterward,  I  first 
saw  him.  There  was  then  considerable  swelling  around  the 
wound,  but  the  motions  of  the  joint  were  free,  and  unattended 

units  among  thousands  giving  contrary  results,  and  were  no  refer- 
ence made  to  these  greater  numbers  which  enlarged  experience 
shows  must  perish  in  vuin  attempts  to  save  limbs,  an  immense  sacri- 
fice of  life  and  increase  of  human  suffering  would  inevitably  follow." 
Guthrie,  after  emphatically  protesting  against  our  being  guided  by 
these  exceptional  cases,  says:  "If  one  case  of  recovery  should  take 
place  in  fifty,  is  it  any  sort  of  equivalent  for  the  sacrifice  of  the  other 
forty  nine?  Or  is  the  preserving  of  a  limb  of  this  kind  an  equiva- 
lent for  the  loss  of  one  mail?" 


286  SURGERY   OF   THE   CRIMEAN    WAR. 

by  almost  any  pain,  and  there  was  no  swelling  whatever  of 
the  articulation.  There  was  one  small  spot  over  the  head 
of  the  fibula,  of  which  he  greatly  complained.  Two  tracks 
seemed  to  lead  from  the  wound.  One  ran  toward  the  inner 
side  of  the  joint,  and  the  other  went  along  its  external 
aspect;  both  were  quite  superficial.  The  position  of  the 
ball  could  by  no  means  be  determined.  The  patient's  youth 
and  strength,  the  absence  of  positive  proof  that  the  articula- 
tion had  been  opened,  together  with  the  possibility  there 
existed  of  the  ball  having  been  deflected,  and  having  passed 
down  by  the  track  along  the  external  aspect  of  the  limb 
and  lodged  about  the  place  so  loudly  complained  of,  in  the 
neighborhood  of  the  head  of  the  .fibula,  made  us  determine 
to  wait.  The  most  decided  measures  were  immediately 
taken  to  ward  off  inflammation.  The  joint  was  fixed,  and 
as  he  was  taken  on  board  ship  and  put  under  the  immediate 
charge  of  my  friend  Mr.  White  of  the  3d  Dragoon  Guards, 
every  care  was  bestowed  on  him.  On  the  24th  there  was 
some  swelling  of  the  joint,  accompanied  with  pain.  The 
wound  of  entrance  was  beginning  to  suppurate  well.  Syno- 
via had  not  been  seen  to  escape.  His  pulse  was  78  and 
soft,  and  his  secretions  were  natural.  The  penetration  of 
the  joint  was  believed  by  all,  still  an  attempt  to  save  the 
limb  was  determined  on.  The  usual  local  and  constitu- 
tional antiphlogistic  remedies,  including  evaporating  lotions, 
fomentations,  leeches  and  cupping,  antimony  and  calomel, 
were  diligently  put  into  requisition.  By  the  30th,  the  joint 
was  much  swollen,  and  very  painful  on  pressure.  A  spot, 
about  the  size  of  a  shilling,  over  the  head  of  the  tibia,  was 
exquisitely  tender.  He  was  feverish  at  night,  when  the  pain 
was  always  much  exacerbated.  An  abscess  formed  among 
the  muscles  of  the  thigh,  and  continued  to  suppurate  pro- 
fusely after  being  opened.  It  had  no  apparent  connection 
with  the  joint.  Slight  hectic  set  in.  The  pain  in  the  joint 
became  lancinating  and  throbbing  to  a  most  harassing  de- 
gree, particularly  over  the  head  of  the  leg  bones  and  over 


GUNSHOT    WOUNDS   OF   JOINTS.  2S7 

the  patella.  The  articulation  assumed  all  the  appearance 
and  feel  of  a  joint  affected  with  white  swelling.  This  was 
the  state  of  things  by  November  19th,  when  amputation  was 
finally  decided  on,  and  performed  in  the  middle  of  the  thigh, 
the  state  of  the  limb  not  allowing  of  its  performance  lower 
down.  On  the  1st  December  he  was  transferred  to  the 
Castle  Hospital  at  Balaklava,  at  which  date  the  stump  was 
suppurating  kindly,  but  an  erythematous  blush  overspread 
the  integuments  of  the  limb  as  high  as  the  hip.  This  dis- 
appeared in  a  day  or  two,  and  the  stump  cicatrized,  all  ex- 
cept a  small  part  in  the  center.  His  strength  seemed  to 
improve.  On  the  4th,  he  had  a  slight  rigor,  which  was 
repeated  twice  daily.  He  gradually  sank,  had  cold  sweats, 
dyspnoea,  diarrhoea,  and  died  on  the  8th.  The  end  of  the 
stump  was  hollow,  and  contained  much  pus,  and  half  an  inch 
of  the  end  of  the  femur  was  dead.  The  lungs  were  con- 
gested, but  beyond  this  no  particular  appearance  was  ob- 
served. The  vessels  of  the  stump  seemed  healthy.  In  the 
removed  limb,  the  tissues  around  the  knee-joint  were  found 
much  engorged,  the  articular  cartilages  and  ligaments  were 
quite  disorganized,  and  the  cavity  filled  with  turbid  purulent 
fluid.  The  ball  lay  below  the  patella,  in  the  intercondyloid 
notch.  Its  pressure  on  the  end  of  the  femur,  lower  surface 
of  patella,  and  head  of  the  tibia  was  marked  by  complete 
erosion  of  the  cartilages  on  these  points.  The  bones  were 
not  otherwise  injured.  This  case  is  highly  interesting,  not 
only  on  account  of  the  difficulty  found  in  detecting  the  ball, 
lying  in  the  position  it  occupied,  but  also  from  the  uncer- 
tainty which  marked  the  line  of  procedure  at  the  outset,  the 
long  absence  of  serious  symptoms,  the  snialluess  of  the  ball, 
and  the  fatal  result,  notwithstanding  the  slight  injury  to  the 
bones.  If  a  free  opening  had  been  made  early  into  the 
articulation,  might  we  not  have  saved  life  and  liinb  ? 

Miller,  private,  31st  Regiment,  was  admitted  into  the 
general  hospital  on  the  9th  July.  While  his  left  leg  was 
coming  forward,  as  he  was  marching  down  to  the  trenches, 


288          SURGERY  OF  THE  CRIMEAN  WAR. 

he  was  struck  by  a  piece  of  shell  over  the  lower  end  of  the 
femur  and  the  external  surface  of  the  knee-joint.  The 
wound  was  about  four  inches  long,  little  lacerated,  but  deep, 
and  opened  the  joint.  The  wound  was  carefully  closed  by 
suture,  the  limb  fixed,  and  cold  was  applied.  Inflammation 
was  violent  by  the  16th,  notwithstanding  the  employment  of 
every  means  to  moderate  it.  The  wound  opened  and  syno- 
via escaped  freely.  The  constitution  did  not  apparently 
sympathize  much  for  many  days  after  the  local  inflammation 
was  considerable.  Pus  was  poured  out  freely  by  1  he  wound, 
symptoms  of  pyaBmia  rapidly  set  in,  and  he  ultimately  died 
on  the  3d  of  August.  The  external  condyle  was  splintered 
into  the  joint,  the  cartilages  were  eroded,  but  little  fluid  ex- 
isted in  the  articulation.  If  the  joint  had  been  freely  laid 
open  after  the  wound  had  failed  to  adhere,  might  not  a 
better  result  have  been  reasonably  looked  for? 

Shell  wounds  of  the  knee  are  as  a  whole  not  so  dangerous 
as  bullet  wounds.  They  frequently  merely  cut  the  soft 
parts  open  ;  or  if  they  injure  the  bone,  the  larger  aperture 
which  they  leave  acts  beneficially  in  permitting  the  free  dis- 
charge of  secretions.  I  have  known  many  shell  wounds  in 
the  neighborhood  of  the  joint,  and  not  a  few  in  which  the 
articulation  was  opened  and  even  the  bones  injured,  ulti- 
mately do  well,  so  far  as  saving  the  limb  goes ;  more  or  less 
anchylosis  following.  The  following  short  notes  of  three 
cases  of  this  description  were  kindly  sent  me  from  Chatham, 
and  are  of  more  use  as  bearing  on  this  point  than  other 
cases  the  outlines  of  which  I  possess,  as  they  record  the 
state  of  the  patient  some  time  after  being  injured  :  Patrick 
Madden,  private,  49th  Regiment,  was  struck  by  a  piece  of 
shell  on  the  left  knee,  when  in  the  trenches,  on  the  30th  of 
May,  1855.  The  joint,  if  not  opened,  was  very  gravely  in- 
jured. He  was  two  months  under  treatment  in  the  Crimea, 
with  his  articulation  much  swollen  and  inflamed,  and  when 
he  reached  England  the  wound  had  healed.  He  was  inva- 
lided on  account  of  "swelling,  pain,  and  weakness  of  left 


GUNSHOT    WOUNDS   OF   JOINTS.  289 

knee,"  the  joint  being  partially  anchylosed  and  its  tissues 
thickened. 

Private  John  Dwyer,  49th  Regiment,  aged  29,  was  in- 
valided on  the  23d  of  April,  1856,  for  "partial  stiffness  of 
the  left  knee,"  occasioned  by  a  shell  wound  which  partially 
fractured  the  patella. 

Private  James  Callaghan,  95th  Regiment,  aged  21,  was 
invalided  at  the  same  station,  on  the  14th  of  April,  1856, 
for  "  anchylosis  of  the  left  knee."  This  man  had  received  a 
shell  wound  of  the  joint,  but  no  mention  is  made  of  any 
fracture  of  the  bones.  The  articulation  was  still  painful  at 
the  period  he  was  invalided. 

A  paymaster-sergeant,  belonging  to  the  38th  Regiment, 
a  dissipated,  nervous  man,  was  admitted  into  the  general 
hospital  on  the  18th  of  June.  While  kneeling,  he  was 
struck  on  the  knee  of  the  limb  not  on  the  ground,  by  a  piece 
of  shell,  which  was  supposed  to  have  lodged.  The  wound 
appeared  to  lead  into  the  cavity  of  the  joint,  and  much  in- 
jury of  the  head  of  the  tibia  had  been  evidently  produced. 
The  patient  would  not  consent  to  the  removal  of  his  limb, 
and  being  a  non-couimissioned  officer,  his  desire  was  complied 
with.  The  limb  was  slightly  bent,  and  laid  on  a  pillow, 
while  local  and  constitutional  remedies  were  promptly  ap- 
plied. For  eight  or  ten  days  no  disturbance,  local  or  con- 
stitutional, supervened.  The  joint  then  began  to  swell,  be- 
came glazed  and  painful,  and  his  stomach  became  irritable. 
The  pain  was  chiefly  confined  to  a  point  on  the  inner  side 
of  the  joint.  He  went  on,  one  day  better  and  another  worse, 
the  joint  always  becoming  more  hopelessly  diseased,  till 
July  15th,  when  the  limb  was  removed.  For  a  time  he  did 
well,  but  ultimately  sank  in  the  beginning  of  August.  The 
head  of  the  tibia  was  much  injured  and  split  into  the  joint, 
while  part  of  its  shaft  was  driven  upward  into  the  cavity 
and  indented  the  condyle  of  the  femur.  A  piece  of  the  head 
of  the  tibia  was  also  driven  downward  and  was  impacted  in 
its  own  shaft.  The  articulation  was  filled  with  a  dirty  pink- 

25 


290  SURGERY   OF   THE    CRIMEAN    WAR. 

colored  matter,  but  the  cartilages  were  not  diseased.  The 
flaps  had  adhered  to  a  considerable  extent,  but  within  them 
a  large  cavity  was  found  filled  with  pus,  decomposed  tissue, 
and  blood.  This  cavity  extended  up  along  the  external  sur- 
face of  the  bone  to  the  trochanter  major.  This  case  was  an 
example  of  a  large  class  in  which  amputation  was  performed 
late  for  gunshot  wounds  of  the  knee,  and  in  which  this  large 
depot  of  pus  had  formed.  These  are  cases  in  which  ad- 
hesion of  the  flaps  by  the  first  intention  should  never  be  at- 
tempted, but  the  utmost  facility  given  for  the  escape  of 
matter. 

I  have  seen  only  one  case  in  which  the  patella  being 
fractured  by  a  ball,  the  joint  was  not  at  the  same  time 
opened.  The  bone  was  in  that  case  "starred,"  but  the  ball 
did  not  lodge.  The  subsequent  inflammation  of  the  joint 
was  slight,  and  the  recovery  good,  the  motion  of  the  joint 
being,  however,  considerably  interfered  with. 

Penetrating1  wounds  of  the  ankle  generally  did  well, 
although  they  required  long  treatment.  This  is  opposed  to 
the  usual  experience  of  such  injuries,  but  very  much  seemed 
to  depend  on  attention  to  two  things — first,  that  the  articu- 
lation was  rendered  perfectly  immovable ;  and,  secondly, 
that  one  or  other  of  the  wounds  was  so  enlarged  as  to  allow 
of  the  free  escape  of  all  discharges.  If  the  original  wounds 
were  large  they  generally  did  best,  as  surgeons  are  unfortu- 
nately averse  to  render  them  free  if  they  are  not  so  origin- 
ally.* The  truth  of  this  remark  I  have  had  ample  oppor- 

*  This  observation  is  as  old  as  Ledran,  who  says :  "  Sur  ce  prin- 
cipe  j'ajouterai  qu'une  playe  dans  laquelle  toute  la  moitie  d'une 
jointure  serait  emportee  doit  etre  regardee  comine  beaucoup  inoins 
dangereuse  qu'une  playe  qui  la  perceroit  de  part  en  part."  "Con- 
trary to  the  general  impression,"  says  Alcock,  "I  am  strongly 
inclined  to  the  conclusion  that  injuries  to  joints  are  not  fatal  in  pro- 
portion to  the  extent  of  surface  laid  open.  The  most  dangerous  of 
these  wounds  I  believe  to  be  punctured,  or  such  wounds  as  a  musket- 
ball  creates — a  small  lacerated  and  contused  opening,  with  more  or 
less  mischief  to  the  internal  parts." 


GUNSHOT    WOUNDS   OF   JOINTS.  291 

tuirity  of  verifying.  Stromeyer  is  of  opinion  that  if  there  is 
much  destruction  of  the  external  malleolus,  we  should  remove 
the  limb,  as  the  foot  takes  on  the  appearance  of  valgus,  and 
is  useless.  I  have  not  observed  this  result. 

The  shoulder-joint  has  recovered  well  in  several  cases 
which  I  have  noticed,  where  a  ball  has  passed  through  part 
of  it,  and  even  in  cases  in  which  a  good  deal  of  the  head  of 
the  bone  has  been  destroyed.  I  suspect,  however,  that  the 
after-consequences  are  not  always  so  encouraging  as  the 
rapid  healing  would  lead  us  to  expect.  I  have  under  my 
charge,  at  the  present  moment,  an  officer  who  was  wounded 
at  the  cavalry  charge  at  Balaklava,  by  a  rifle-ball  which 
shattered  part  of  the  scapula  and  the  head  of  the  humerus. 
Nothing  was  done  in  the  way  of  extracting  the  broken  frag- 
ments at  the  time  of  injury ;  and  accordingly,  besides  the 
hazards  of  a  very  long  and  tedious  suppuration,  during 
which  many  considerable  spicula3  have  been  extruded,  and 
the  formation  and  evacuation  of  long  "  fusees"  of  pus,  he  is 
yet  subject  to  a  constant  recurrence  of  these  purulent  forma- 
tions, and  to  the  exfoliations  of  pieces  of  bone  which  seem 
to  be  set  loose  by  the  least  overexertion.  His  joint  is  quite 
anchylosed.  If  excision  had  been  practiced  early,  might  not 
a  more  useful  limb  have  been  retained,  and  much  annoyance 
avoided  ? 

The  much  greater  simplicity  and  superficial  position  of 
the  shoulder  than  of  the  other  articulations,  cause  it  both 
to  suffer  less  and  to  be  more  manageable  when  injured. 
Balls  sometimes  pass  very  close  to  the  capsule  without  open- 
ing it,  or,  at  any  rate,  injure  it  but  slightly.  Of  this,  I  be- 
lieve, I  have  seen  several  instances.  Larrey  has  recorded  a 
case  in  which  a  round  shot  passed  across  the  shoulder-joint ; 
and  although  it  only  abraded  the  skin,  it  yet  shattered  the 
head  of  the  humerus,  the  scapular  end  of  the  clavicle,  as  well 
as  the  acromion  and  coracoid  processes.  This  man  was 
saved  by  the  excision  of  the  destroyed  bone.  He  tells  us 
he  saved  many  cases  in  which  the  opening  into  the  joint 
was  not  great. 


292  SURGERY    OP   THE    CRIMEAN    WAR. 

If  a  ball  remains  impacted  in  the  head  of  the  bone,  as  it 
sometimes  is  known  to  do,  then  the  sooner  it  is  got  rid  of 
the  better,  as  caries  of  the  bone,  disease  of  the  joint,  and 
either  amputation  or  death  will  follow.  One  case  occurred 
at  Scutari,  in  which  the  ball  was  found  after  death  firmly 
impacted  in  the  round  head  of  the  bone.  I  find  the  report 
of  a  similar  case  as  having  occurred  in  one  of  the  regiments 
serving  in  China  in  1841-42.  In  this  case  also  the  ball  was 
not  removed,  necrosis  was  caused,  and  the  patient  died  of 
exhaustion  on  the  fiftieth  day.  Malgaigne,  however,  reports 
a  case  in  which  a  ball  had  been  so  englobed,  and  no  disease 
whatever  caused  in  the  bone,  where  a  considerable  cavity 
contained  the  ball.  Abscesses  and  fistulous  tracks  are  the 
things  most  to  be  dreaded  in  all  cases  in  which  the  shoulder- 
joint  is  implicated  in  gunshot  wounds. 

In  the  following  case  of  penetration  of  the  elbow,  the 
distinction  between  a  wound  caused  by  a  sword-cut  from 
one  made  by  a  ball  was  well  shown.  If  a  ball  had  passed 
across  the  articulation,  fracturing  the  bones,  excision  would 
have  been  called  for :  A  dragoon  was  cut  across  the  elbow 
of  his  sword  arm  by  a  Russian  horseman,  at  the  heavy 
cavalry  charge  at  Balaklava.  The  olecranon  was  completely 
detached,  and  the  joint  opened.  The  wound  was  imme- 
diately closed,  the  arm  placed  in  an  extended  position,  and 
cold  employed  to  allay  inflammation.  Little  more  was  done, 
and  the  divided  surfaces  quickly  adhered,  and  an  arm  re- 
mained which,  although  not  so  free  in  its  motions  at  that 
joint  as  it  was  formerly,  was  yet  most  useful,  and  would,  I 
doubt  not,  become  more  so  in  time.  Abscesses  around  the 
joint  and  cedematous  swellings  of  the  hand  and  arm  are 
very  apt  to  follow  injuries  of  the  elbow.  Larrey  thought 
gunshot  wounds  of  the  elbow  particularly  dangerous,  from 
the  strong  ligaments  which  surround  it,  and  the  little  dis- 
tensibility  of  the  joint ;  and  he  recommends  amputation 
when  it  has  been  largely  opened,  even  by  a  cutting  instru- 
ment, and  blood  has  been  effused  into  the  cavity.  I  have  seen 


GUNSHOT   WOUNDS   OF   JOINTS.  293 

several  cases  in  which,  after  being  traversed  by  a  ball,  attempts 
have  been  made  to  save  the  elbow  without  excising  it,  but 
such  trials  were  anything  but  encouraging.  The  motion  of 
the  joint,  and  its  consequent  use,  will  be  found  much  greater 
after  excision  than  when  the  arm  has  been  saved  without 
such  an  operation.  Dupuytren  has  pointed  out  how  im- 
portant in  gunshot  wounds  of  the  elbow  the  position  of  the 
aperture  is.  If  at  its  inner  aspect,  the  secretions  get  easy 
exit  when  the  limb  is  in  its  natural  position,  and  thus 
the  chance  of  a  favorable  result  is  greater ;  if,  on  the  con- 
trary, the  orifice  be  on  the  outer  aspect  of  the  articulation, 
no  position  will  allow  of  the  free  flow  of  the  pus  except  one, 
which  will  prove  very  fatiguing,  and  almost  impossible  to 
maintain  for  a  long  period. 

The  Returns  show  the  following  results  as  having  been 
obtained  from  the  resection  of  joints,  from  the  1st  April, 
1855,  till  the  end  of  the  war.  The  imperfect  state  of  the 
official  documents  makes  accuracy  impossible  with  regard  to 
the  earlier  part  of  the  campaign  : — 

Head  of  femur ">,  primary,  of  which  1  recovered. 

"•  "       1,  secondary,  fatal. 

Knee-joint „   1,  secondary,  fatal. ~ 

Os  calcis,  and  part  of  astragalus.   1,  recovered. 

Os  calcis  alone 1,  recovered. 

Head  of  humerus 8.  primary  cases,  1  death.* 

*  Larrey  performed  excision  of  the  shoulder  in  Egypt  10  times; 
4  died — 2  of  scorbutus,  1  of  hospital  fever,  and  1  of  pest,  after  re- 
covery. In  1795  Percy  mentioned  19  cures  after  excision  of  the 
shoulder.  Baudens  had  13  recoveries  from  14  operations,  (Rev.  M»L 
de  Chlr.,  March,  18-">5.)  Of  19  operations  performed  in  Sleswick  7 
were  fatal,  most  of  them  from  pyiumia.  Legouest  had  G  cases  of 
primary  resection  of  the  shoulder  in  the  hospital  at  Constantinople, 
of  which  2  recovered.  Thus,  then,  Hennen  showed  little  discrimina- 
tion in  condemning  the  operation,  when  he  says  that  it  was  "more 
imposing  in  the  closet  than  applicable  to  the  field." 

25* 


294  SURGERY   OF   THE   CRIMEAN    WAR. 

Cases. 

Head  of  humerua 5,  secondary,  no  death. 

"     and  part  of  scapula 1,  secondary  case,  followed  by  death. 

Elbow-joint 18,  primarv,  with  three  deaths. 

"         "      4,  secondary,  died  from  causes  not 

connected  with  the  operation. 
Partial  of  elbow-joint 8,  no  death. 

The  above  lists  by  no  means  represent  the  whole  number 
operated  on.  Those  who  underwent  operation  after  the 
Alma  and  Inkerman,  after  the  battle  of  Balaklava,  and  the 
first  winter's  work  in  the  trenches,  are  all  excluded,  and 
thus  a  vast  number  of  the  operations  of  the  early  part  of 
the  war  are  omitted.  In  fact,  I  cannot  but  think  that  in 
this  way  the  majority  of  the  operations  do  not  appear,  as 
the  number  performed  after  these  early  engagements  must 
have  exceeded  those  executed  at  a  subsequent  period. 

The  excisions  of  articulations  injured  by  balls,  although 
occasionally  performed  during  the  Peninsular  war,  never  be- 
came a  very  general  practice,  nor  was  it  applied  to  some  of 
the  joints  which  later  years  have  shown  its  advantages  in. 
The  Sleswick-Holstein  campaign  was  the  first  great  war  in 
which  this  conservative  proceeding  was  followed  out  on  an 
extensive  scale ;  and  the  results  obtained  by  Langenbeck 
and  Stromeyer  attest  its  efficiency,  although  they  appear  to 
have  had  recourse  to  it  in  cases  of  very  slight  injury.  These 
operations  certainly  mark  the  surgery  of  the  age,  as,  in  the 
words  of  Malgaigne,  it  may  be  said  :  "  C'est  une  des  plus 
heureuses  tendances  de  la  chirurgie  de  ce  siecle,  quand  la 
necessite  lui  metle  couteau  a  la  main  de  ne  lui  conce'der  que 
ce  quelle  ne  pent  lui  ravir,  de  sacrifier  aussi  peu,  et  de  con- 
server  autant  que  possible." 

The  Crimean  war  afforded  a  considerable  number  of  cases 
adapted  to  the  performance  of  resection ;  and  I  think  our 
results  will  stand  a  fair  comparison  with  others,  when  all  the 
circumstances  are  taken  into  account.  I  will  not  say  that 
excision  was  performed  in  as  large  a  proportion  of  cases  of 
injury  of  the  joints  as  we  were  led  to  hope  at  the  outset  of 


GUNSHOT    WOUNDS   OP   JOINTS.  295 

the  war  it  might  be ;  but  when  a  better  acquaintance  was 
had  with  the  character  of  the  wounds  which  this  war  pre- 
sented to  us,  it  was  easy  to  understand  how  such  should  be 
the  case.  The  shafts  of  the  bones  leading  from  the  joints 
were  often  too  extensively  destroyed  to  enable  the  injured 
parts  to  be  removed  by  excision ;  in  fact,  the  shafts  were  so 
often  split,  and  their  periosteal  and  medullary  membranes 
destroyed,  that  the  resection  of  the  articulation  did  not  suf- 
fice to  save  the  limb.  Surgeons  soon  recognized  this  ;  but 
yet  it  was  by  no  means  always  easy  to  determine  the  true 
state  of  things  about  the  joint  till  the  incisions  necessary 
for  resection  laid  bare  the  bones,  and  forced  the  reluctant 
operator  to  convert  his  operation  into  one  of  amputation. 

The  great  success  which  has  attended  the  excision  of 
joints  in  civil  practice,  and  a  consideration  of  the  fact  that 
the  cnses  which  fall  to  be  operated  on  in  the  field  are  free 
not  only  of  local  affections  in  the  articulation,  but  also  of 
any  active  constitutional  disease,  made  us  all  naturally  san- 
guine of  obtaining  the  best  results  from  such  operations  in 
the  field;  but  unfortunately  the  circumstances  above  referred 
to  interfered  so  as  frequently  to  leave  us  no  alternative  but 
amputation. 

So  far  as  my  observation  went,  primary  excisions  were 
much  more  successful  than  those  done  at  a  late  date  ;  and 
this  fact  is  evidenced  both  as  regards  the  final  results  and 
the  length  of  the  period  of  convalescence,  so  far  as  we  have 
returns. 

One  advantage,  with  regard  to  the  opportunity  of  per- 
forming resections  early,  is  that  we  can  in  general  tell  at 
first  sight  that  such  an  operation  at  least  is  called  for.  It 
is  not  so  with  regard  to  a  large  number  of  cases  for  ampu- 
tation ;  but  generally  we  can  see  at  once  that  excision,  at 
any  rate,  must  be  performed,  although  we  may  not  be  able 
to  determine  that  subsequent  amputation  will  not  be  re- 
quired. 

In  the  following  observations  I  have  not  referred  to  the 


296  SURGERY   OF    THE    CRIMEAN    WAR. 

amount  of  mobility  retained  by  the  joint  after  our  excisions, 
as  the  patients  went  from  under  my  notice  too  soon  for  my 
being  able  to  do  so.  It  is  certainly  among  the  disadvant- 
ages of  military  practice  during  war  that  one  can  seldom 
trace  cases  to  a  conclusion  ;  not  only  so,  but,  in  such  cases 
as  those  of  resected  joints,  very  much  of  the  after-result 
depends  on  that  careful  attention  which  no  one  can  render 
so  scrupulously  as  the  operator  himself ;  and  as  it  is  never 
in  his  power  to  bestow  this,  we  are  not  likely  to  have  such 
favorable  results  as  when,  in  civil  practice,  the  patient  re- 
mains, till  finally  cured,  under  the  same  hand. 

The  shoulder -joint  is  certainly  that  to  which  resection  is 
most  peculiarly  applicable,  from  its  superficial  position  and 
simple  construction.  Interference  with  this  articulation  is, 
therefore,  less  disturbing  to  the  constitution  of  the  patient, 
and  the  results  of  the  operation  are  more  satisfactory,  than 
those  which  follow  a  like  interference  with  any  of  the  other 
large  joints. 

The  experience  of  the  surgeons  in  Sleswick-Holstein  led 
them  to  conclude  that  secondary  operation  is  less  unfavora- 
ble when  the  shoulder-joint  is  implicated  than  when  a  late 
operation  is  performed  on  any  other  joint.  The  only  sec- 
ondary excisions  of  the  shoulder-joint  which  appear  in  the 
Crimean  returns  seem  to  have  been  successful. 

I  know  of  a  few  cases  in  which  what  may  be  termed  par- 
tial resections  of  the  shoulder  were  performed,  i.e.  cases  in 
which  less  or  more  of  the  head  of  the  humerus  was  extracted, 
without  the  whole  being  removed  ;  and  I  believe  the  result 
of  such  cases  to  have  been,  on  the  whole,  satisfactory,  so  far, 
at  least,  as  the  healing  of  the  wound  was  concerned.  It  is 
most  curious  how  much  can  be  done  in  this  way.  The  after- 
mobility  of  the  articulation  will,  however,  be  more  restricted 
in  these  partial  excisions  than  if  the  whole  joint  is  resected, 
and  thus  an  entirely  new  joint-formation  permitted.  The 
instances  were  not,  however,  very  numerous  in  which  the 
destruction  of  the  bone  was  so  limited  as  to  allow  of  this 


GUNSHOT    WOUNDS   OP   JOINTS.  297 

partial  resection.  Very  much  depends  on  the  careful  man- 
agement of  these  cases  afterward,  especially  in  guarding 
against  inflammation. 

In  the  old  war,  they  restricted  excision  to  those  cases  in 
which  the  injury  was  confined  to  the  head  of  the  bone,  hold- 
ing that,  when  the  shaft  was  much  implicated,  exarticulation 
should  be  preferred,  and  this  was  very  much  the  doctrine 
acted  on  during  the  Crimean  war.  Guthrie  thought  the 
insertion  of  the  deltoid  the  lowest  point  at  which  the  bone 
could  be  divided  with  any  prospect  of  success  ;  but  Esmarch 
has  shown  that  as  much  as  four  and  a  half  inches  may  be 
removed  from  the  humerus,  and  yet  a  most  useful  arm  re- 
main. The  ligameutous  matter  necessary  to  produce  such 
a  favorable  result  requires  a  "  plasticite "  of  constitution 
which  our  patients  did  not  possess. 

The  fact  so  clearly  brought  out  by  Stromeyer  should  be 
always  borne  in  mind,  in  determining  on  operations  at  the 
shoulder-joint,  that  in  comminution  of  the  shaft  of  a  long 
bone,  the  fissures  never  extend  into  the  epiphysis ;  in  the 
same  manner,  injuries  of  the  epiphysis'  only  in  extremely 
rare  cases  extend  into  the  shaft  unless  the  bullet  strikes  the 
adjoining  borders  of  both  parts,  in  which  case  both  are  usu- 
ally more  or  less  seriously  comminuted. 

As  to  the  best  method  of  proceeding  for  resecting  the 
head  of  the  humerus,  some  little  difference  exists,  as  is  the 
case  with  regard  to  the  excision  of  some  of  the  other  joints 
also,  between  those  methods  adapted  for  military  and  civil 
practice.  This  arises,  in  a  great  measure,  from  the  character 
of  the  injuries  necessitating  the  operation  in  either  case. 
The  soft  parts  suffer  little,  and  the  bone  is  not  diseased, 
although  broken,  in  cases  operated  on  in  the  field,  nor  are 
the  parts  bound  together,  as  they  so  often  are  in  the  exci- 
sions performed  in  civil  hospitals;  hence  it  follows  that  we 
can  often  remove  all  that  is  necessary  through  a  much  more 
limited  incision  of  the  soft  parts,  than  we  could  if  disease 
was  the  cause  of  the  operation,  or  yet  many  of  the  accidents 


298  SUBGERY    OF    THE    CRIMEAN    WAR. 

which  occur  in  civil  life,  in  which,  although  the  joint  may  be 
but  slightly  implicated,  the  soft  parts  are  yet  so  often  greatly 
destroyed.  In  the  case  of  gunshot  wounds,  too,  the  perios- 
teum, as  well  as  the  ligamentous  and  muscular  tissues  of 
the  articulation,  can  be  retained,  and  thus  a  very  great 
advantage  is  secured,  according  to  the  views  of  this  opera- 
tion set  forth  by  Stromeyer  and  Baudens.  A  single  straight 
incision  will  thus  then  very  often  suffice  in  resecting  either 
the  shoulder  or  elbow  joint,  and  even  in  similar  operations 
on  the  knee  and  hip,  so  that  the  maxim  of  Desault,  that 
"the  simplicity  of  an  operation  is  the  measure  of  its  perfec- 
tion," is  perhaps  better  exemplified  in  military  than  in  civil 
practice.  However,  as  in  gunshot  wounds  two  apertures 
commonly  exist,  and  as  it  is  desirable  to  include  them  if 
possible  in  the  incision,  we  have  a  further  illustration  of  the 
saying,  that  the  surgeon  should  be  bound  to  no  particular 
form  of  operation,  but  should  adapt  his  proceedings  to  his 
case. 

One  of  the  chief  dangers  following  resection  of  the  shoulder 
is  the  formation  of  sinuses  and  abscesses  in  the  neighbor- 
hood. The  best  mode  of  avoiding  this,  is  to  arrange  the 
line  of  incision  so  as  to  give  free  exit  to  the  pus.  Stro- 
meyer's  semicircular  incision  over  the  posterior  surface  of 
the  articulation  fulfills  this  end  better  perhaps  than  any 
other.  The  joint  is  there  very  easily  got  at.  Langenbeck's 
one  straight  incision  on  the  anterior  aspect  of  the  articula- 
tion, with  or  without  the  transverse  cut  suggested  by  Franke, 
gave  much  satisfaction  in  Sleswick,  where  it  was  largely  put 
in  practice ;  and  I  have  myself  seen  most  admirable  results 
got  by  the  straight  incision  of  White  through  the  deltoid : 
but  Stromeyer's  allows  of  the  more  rapid  discharge  of  all 
secretions  than  any  of  the  others.  Baudens,  as  is  well 
known,  prefers  a  straight  incision  on  the  inside  of  the  joint 
in  front,  and  from  his  large  practice  of  it  in  Africa  was 
highly  pleased  with  its  efficiency,  believing  that  it  best 
allows  of  that  ginglymoid  joint  being  formed,  which,  he  says, 


GUNSHOT   WOUNDS   OP   JOINTS.  299 

takes  the  place  of  the  former  articulation.  Whichever  of 
these  methods  of  operation  we  adopt — and  they  represent 
those  which  have  received  the  preference  from  military 
surgeons  during  late  wars — it  seems  conceded  by  them  all, 
that  we  do  not  require  in  field  practice  such  extensive  in- 
cisions as  we  do  in  civil  life,  and  that  by  such  limited  incision 
the  muscular  and  tendinous  parts  can  be  more  respected, 
and  thus  the  hope  of  restored  action  be  much  increased. 
The  report  of  Esmarch,  on  the  practice  of  Stromeyer  and 
Franke,  shows  us  that  to  cut  across  the  fibers  of  the  deltoid 
does  not  much  interfere  with  its  after-usefulness,  "as  its 
upper  edge  applied  itself  to  and  united  with  the  articular 
surface  of  the  scapula,  and  was  thus  fully  attached  and  able 
to  raise  the  arm.  The  healing  was  also  quicker,  as  the 
space  to  be  filled  by  granulation  was  much  diminished  in 
size  by  the  application  of  the  muscle  to  the  glenoid  fossa." 

When  the  neck  of  the  bone  is  broken  here,  as  in  the  hip, 
so  that  it  is  difficult  to  seize  the  round  head  of  the  bone, 
the  powerful  forceps  used  by  Mr.  Ferguson  in  excision  of 
the  jaw,  will  be  found  to  do  good  service. 

Resections  of  the  elbow-joint  were  more  numerous  in  our 
army  than  in  the  French,  yet  the  number  of  cases  adapted 
for  it  in  either  force  was  but  small.  The  numbers  mentioned 
in  the  returns  by  no  means,  however,  include  all  the  opera- 
tions of  this  kind  which  were  performed.* 

The  formation  of  the  elbow  makes  gunshot  injuries  of  it 
much  more  serious  than  those  which  implicate  the  shoulder. 
Larrey  was  particularly  gloomy  in  his  prognosis  of  wounds 
of  the  elbow,  and  reports  many  disasters  from  them.  That 
resection  of  the  elbow  is  much  less  fatal  then  amputation, 
does  not  call  for  proof  now-a-days,  as  it  has  been  a  long- 

*  Dr.  John  Thomson  seems  not  to  have  been  sanguine  of  the  re- 
sulis  to  be  obtained  from  excision  as  applied  to  either  the  shoulder 
or  elbow.  Of  the  hitter  he  says:  "I  am  satisfied  that  the  difficulty 
of  the  operation,  and  the  great  length  of  time  and  care  necessary  Cor 
the  cure,  must  prevent  its  adoption  in  military  practice." 


300  SURGERY    OF   THE    CRIMEAN    WAR. 

established  fact.  The  question  now  is  more  as  to  the  extent 
of  the  articular  ends  of  the  bones  which  can  be  removed, 
consistently  with  retaining  a  useful  joint.  My  notes  of  cases 
occurring  in  the  Crimea,  unfortunately,  do  not  enable  me  to 
throw  any  light  on  these  interesting  points.  In  Sleswick, 
out  of  forty  excisions,  only  six  patients  died,  and  two  others 
were  unsuccessful ;  but  in  thirty-two  instances  the  effect  was 
very  good.  "As  regards  two  of  them,"  says  Esmarch,  "  I 
have  not  been  able  to  learn  anything  with  reference  to  the 
power  of  motion  they  possess ;  of  the  rest,  eight  have  very 
extensive,  nine  more  or  less  complete,  power  of  motion ;  it 
is  to  be  hoped  of  many  of  the  remainder,  that  they  will  be 
able  to  obtain  much  increased  mobility  by  means  of  zealous 
exercise  of  the  arm.  On  the  other  hand,  thirteen  of  the 
cases  have  a  more  or  less  complete  anchylosis  of  the  joint." 

Several  of  the  cases  operated  on  in  the  East  had  under- 
gone injury  of  all  the  bones  entering  into  the  joint,  but  no 
case  came  under  my  notice  in  which  so  much  as  four  or  five 
inches  were  removed,  as  was  done  in  the  war  in  the  Duchies. 

Partial  resection — of  which  there  were  a  good  many  cases 
— did  not,  I  think,  turn  out,  on  the  whole,  at  all  so  well  as 
complete  ones.  They  were  more  tedious,  more  liable  to 
fail,  and  less  satisfactory  when  they  succeeded,  than  when 
the  whole  articulation  was  removed.  The  following  were 
cases  of  partial  removal  of  the  articulation  : — 

A  soldier  of  the  fusiliers  had  the  head  of  the  radius  and  a 
small  portion  of  the  lesser  sigmoid  notch  removed,  shortly 
after  injury.  Amputation  had  to  be  performed  two  months 
afterward,  there  never  having  been  any  attempt  made  to 
heal  by  the  parts.  A  soldier  of  the  23d  Regiment,  admitted 
into  the  general  hospital  in  camp,  after  the  assault  on  the 
7th  September,  had  the  external  condyle,  the  eminentia 
capitata,  and  part  of  the  trochlea,  destroyed  and  removed, 
the  soft  parts  being  little  injured.  Sloughing  set  in,  great 
constitutional  disturbance  followed,  and  amputation  had  to 
be  performed  three  months  afterward.  If  complete  excision 


GUNSHOT    WOUNDS   OF   JOINTS.  301 

had  been  early  performed  in  both  of  these  cases,  I  believe 
we  might  have  obtained  much  more  happy  results.  These 
are  only  examples  of  several  similar  cases.  But,  on  the 
other  hand,  such  cases  as  the  following  have  occurred :  A 
soldier,  when  mounting  the  heights  of  Alma,  was  struck  by 
a  rifle-ball,  which  passed  across  his  elbow  posteriorly,  frac- 
turing the  heads  of  the  radius  and  ulna,  but  leaving  the 
humerus  entire.  The  broken  fragments  were  removed,  and 
the  humerus  left  untouched ;  and,  after  three  months'  careful 
treatment,  this  patient  was  discharged  with  a  famous  joint, 
which  admitted  of  a  considerable  latitude  of  motion,  and 
with  which  he  could  sustain  no  small  weight  In  the  9th 
Regiment,  a  man  was  struck  by  a  ball,  which  destroyed  the 
inner  condyle  of  the  humerus,  without  injuring  the  ulnar 
nerve.  The  broken  fragments  were  removed  by  Mr.  Thorn- 
ton, surgeon  of  the  regiment.  The  subsequent  inflammation 
was  commanded,  and  an  arm  was  retained,  which  came 
ultimately  to  possess  three-fourths  of  its  original  motion. 
Esrnarch  thinks  that  "the  extensive  severing  of  the  liga- 
mentous  apparatus  of  the  joint  is  what  deprives  the  wound 
of  its  danger,  and  that  the  less  there  is  removed  from  the 
joint  ends  of  the  bones,  the  greater  is  the  probability  of 
anchylosis." 

The  complete  fixture  of  the  joint  during  the  early  period 
of  treatment,  as  so  strongly  dwelt  upon  by  Stromeyer ;  its 
constant  support  by  a  splint,  even  when  being  dressed  ;  the 
elevation  of  it,  so  as  to  prevent  oedema ;  its  flexure  at  an 
angle  of  130°  to  140°,  are  all  points  of  importance,  both 
as  regards  the  comfort  of  the  patient  and  the  after-results. 
Early  passive  motion  before  the  wound  is  wholly  cicatrized, 
but  at  once  abandoned  if  any  irritation  or  signs  of  inflam- 
mation appear,  are  also  indications  which  late  experience 
has  stamped  the  value  of. 

The  hip  was  resected  six  times ;  five  being  primary,  and 
one  a  secondary  operation.  One  of  the  primary  alone  suc- 
ceeded. Such  success,  although  small,  is  yet  encouraging, 


302  SURGERY    OF   THE   CRIMEAN    WAR. 

as  compared  with  the  results  obtained  from  amputation  at 
the  hip,  for  which  operation  the  excisions  were  substituted; 
for,  as  will  be  afterward  seen,  out  of  at  least  10  amputations 
at  this  joint  in  our  army,  and  some  13  among  the  French, 
none  survived,  and  in  our  cases  at  any  rate  the  fatal  result 
very  rapidly  followed  the  operation. 

I  performed  the  first  operation  of  excision  of  the  hip 
undertaken  in  the  East,  on  the  6th  July,  1855,  on  a  rifleman, 
whose  case  is  subjoined  : — 

Couch,  a  soldier  of  the  Rifle  Brigade,  was  struck,  on  the 
18th  of  June,  by  a  ball,  close  below  the  elbow-joint  of  his 
left  arm.  The  ulna  was  fractured  by  the  bullet,  which  then 
struck  the  femur  on  the  great  trochanter  of  the  same  side. 
The  trochanter  and  neck  of  the  bone  was  split,  and  other- 
wise severely  injured.  The  patient  did  not  come  under  my 
care  till  the  5th  of  July,  when  I  found  a  large,  ragged  wound 
over  the  injured  trochanter,  from  which  a  very  profuse  dis- 
charge of  pus  flowed.  At  the  bottom  of  this  wound  the 
bone  was  seen  to  be  hollowed  out  into  a  large  cavity,  and  to 
be  split  in  all  directions.  The  bone  was  black  and  dead. 
The  limb  was  not  shortened  or  distorted.  The  wound  on 
his  arm  gave  him  much  annoyance,  and  the  pain  from  the 
hip  was  so  great  that  he  urgently  requested  some  operation 
to  be  performed,  which  might  relieve  him.  He  was  brought 
under  the  influence  of  chloroform,  in  order  that  the  injury 
might  be  more  completely  examined  than  could  otherwise  be 
accomplished  from  the  patient's  irritable  condition,  and  also 
to  enable  me  to  get  the  limb  put  into  a  proper  apparatus. 
On  enlarging  the  external  wound,  so  as  to  make  it  dependent, 
and  to  allow  the  necessary  steps  to  be  taken  for  the  removal 
of  the  dead  portions  of  bone,  a  large  fragment  of  the  ex- 
ternal part  of  the  femur,  which  comprised  what  remained 
of  the  great  trochanter,  was  found  detached,  and  a  fissure 
running  upward,  apparently  into  the  capsule.  It  was  found 
impossible  to  remove  the  dead  bone  without  opening  the 
joint ;  and,  as  but  a  very  thin  shell  of  the  shaft  was  sound, 


GUNSHOT    WOUNDS   OP    JOINTS.  303 

a  consultation  decided  on  the  propriety  of  excising  the  head 
of  the  bone,  and  removing  along  with  it  what  osseous  sub- 
stance was  destroyed.  This  was  done  without  difficulty,  the 
original  wound  being  increased  a  little  upward.  Hardly  a 
drop  of  blood  was  lost.  The  wound  was  lightly  dressed, 
and  the  limb  fixed  on  an  inclined  plane,  so  arranged  that  the 
large  dependent  opening  retained  could  be  got  at  without 
having  to  remove  the  patient.  The  relief  from  pain  and 
irritation  which  was  experienced  almost  immediately  was 
very  marked  and  gratifying.  Next  day  the  patient's  pulse 
was  firmer,  his  expression  very  markedly  better,  and  he  de- 
clared himself  as  perfectly  at  ease.  The  limb,  in  a  few  days, 
was  shortened  about  two  inches.  Suppuration  became  estab- 
lished ;  his  strength  improved  ;  hectic  disappeared ;  he  slept 
well;  and  his  appetite,  which,  before  the  operation,  was 
nearly  gone,  was  now  restored,  and  he  was  totally  free  from 
pain  or  uneasiness.  His  pulse,  on  an  average,  continued 
about  85  beats  in  the  minute,  and  was  of  good  character. 
He  continued  to  progress  most  favorably  for  about  a  week. 
Part  of  the  wound  closed,  and  the  rest  of  it  was  clean  and 
healthy.  At  the  end  of  that  period  he  was  suddenly  seized 
with  violent  diarrhoea,  accompanied  by  vomiting  and  severe 
cramps,  and  followed  by  suppression  of  urine,  which  con- 
tinued for  18  hours  previous  to  death.  His  stools  soon 
assumed  the  characteristic  appearance  of  cholera  evacu- 
ations, his  strength  sunk,  he  became  rapidly  collapsed,  cold, 
and  blue,  and  died  during  the  night.  Cholera  was  prevalent 
in  the  camp  at  the  time. 

After  death,  some  crude  tubercles  were  found  in  both 
lungs.  There  was  no  symptom  of  purulent  absorption  any- 
where. The  vessels  in  the  neighborhood  of  the  wound  were 
healthy.  There  were  old  ulcerations  in  the  intestine,  and 
recent  enlargement  of  the  solitary  glands.  The  left  ulna 
was  fractured  obliquely  up  toward  the  elbow-joint.  The 
wound  over  the  hip  was  sloughy,  an  action  it  rapidly  took 
on  shortly  previous  to  death,  and  the  cut  end  of  the  bone 


304          SURGERY  OP  THE  CRIMEAN  WAR. 

was  smooth  and  unchanged.  If  I  had  seen  this  patient 
earlier,  when  the  nature  of  the  injury  could  have  been  more 
exactly  determined,  I  would  have  contented  myself  with 
merely  gouging  out  the  destroyed  portion  of  bone,  trusting 
to  the  remaining  scale  to  throw  out  callus,  fixing  the  limb 
carefully,  giving  free  exit  to  the  suppuration,  an  dstrenuously 
supporting  the  patient's  strength.  The  state  of  the  lungs 
and  intestine,  as  revealed  on  post-mortem  examination,  made 
this  patient,  at  best,  but  an  unpromising  subject  for  oper- 
ation; but  if  the  fatal  disease  which  terminated  his  existence 
had  not  supervened,  I  would  have  been  sanguine  of  the 
result.  When  he  came  under  my  care,  I  feel  sure  he  was  in 
such  a  condition  that,  if  no  operation  had  been  undertaken 
to  relieve  him  from  the  mass  of  dead  bone  which  his  system 
was  futilely  trying  to  get  rid  of,  and  which  was  setting  up 
further  disease  all  around  it,  he  would,  in  a  very  few  days, 
have  died,  exhausted  by  suffering.  These  are,  however, 
points  more  easily  settled  on  paper  than  at  the  bedside. 

Mr.  Blenkins,  of  the  Guards,  operated  on  the  next  case, 
and  has  been  good  enough  to  send  me  the  following  notes 
of  it  :— 

"Private  Charles  Monsterey,  aged  24,  third  battalion 
Grenadier  Guards.  Brought  from  the  trenches  at  midnight 
with  a  severe  shell  wound  on  the  outer  side  of  the  right 
thigh.  Examination  showed  the  thigh-bone  to  be  exten- 
sively fractured  at  the  upper  part,  in  the  situation  of  the 
trochanters  and  neck;  the  fragments  were  much  comminuted 
and  the  surrounding  muscles  greatly  lacerated.  It  was  at 
once  recognized  as  an  appropriate  case  for  excision,  and  the 
operation  was  performed  half  an  hour  after  his  arrival  in 
camp.  The  wound  was  extended  in  a  longitudinal  direction 
to  the  extent  nearly  of  five  inches,  and  the  shaft  of  the  femur 
sawn  through  at  the  junction  of  the  upper  fifth  with  the  rest 
of  the  shaft.  The  muscles  were  next  detached  from  the  tro- 
chanter,  and  the  capsule  lastly  divided.  It  was  intended, 
at  first,  to  preserve  the  head  of  the  bone  in  the  socket ;  but 


GUNSHOT   WOUNDS   OP  JOINTS.  305 

the  capsule  was  so  extensively  lacerated,  and  the  cavity  being 
filled  with  blood, .it  was  resolved  to  remove  it.  Yery  little 
blood  was  lost  during  the  operation.  Examination  after- 
ward of  the  excised  bone  showed  it  to  be  fractured  in  four- 
teen pieces.  The  trochanter  minor  formed  three,  trochanter 
major  three,  shaft  five,  the  neck  three,  besides  numerous 
smaller  fragments.  The  case  continued  to  do  well  for  the 
first  three  weeks  ;  healthy  granulations  sprang  up,  both  from 
the  end  of  the  divided  shaft  and  the  surrounding  cavity  and 
acetabulum.  At  this  period  pain  and  swelling  of  the  knee- 
joint  of  the  same  limb  supervened,  the  capsule  of  that  joint 
became  filled  with  purulent  matter,  the  cartilages  eroded, 
and  he  sank  gradually,  worn  out  with  hectic  symptoms,  at 
the  end  of  the  fifth  week,  in  spite  of  every  effort  to  support 
him.  The  case  was  doing  remarkably  well,  and  I  had  every 
hope  of  his  recovery  until  empyema  came  on." 

Staff- Surgeon  Crerar  operated  on  the  third  case,  a  private 
of  the  first  battalion  of  the  Royals,  who  was  wounded  in 
the  Grreenhill  trenches  at  mid-day  on  the  6th  of  August. 
The  wound,  in  this  case,  was  slightly  posterior  to  the  great 
trochanter,  and  was  not  larger  than  a  shilling.  It  had  been 
caused  by  a  piece  of  shell,  which,  before  it  entered  his  thigh, 
had  first  struck  a  water  canteen  that  hung  by  his  hip.  A 
comminuted  fracture  high  up  was  clearly  ascertained ;  but 
its  exact  position  or  extent  was  not  defined  previous  to  op- 
eration, although  it  was  supposed  to  implicate  the  head  and 
neck  of  the  bone.  "  The  trochanter  was  found  broken  into 
several  portions,  detached  and  imbedded  in  the  contused  mus- 
cles around,  from  which  they  were  at  once  removed.  The 
fracture  was  found  to  extend  obliquely  inward  about  an  inch 
and  a  half  along  the  shaft  of  the  bone.  The  femur  was  now 
protruded  through  the  wound,  and  I  sawed  off  the  whole  of 
the  fractured  bone,  leaving  a  smooth,  clean  surface ;  I  then 
proceeded  to  disarticulate  the  head  of  the  femur,  which  was 
effected  without  difficulty.  Scarcely  three  ounces  of  blood 
were  lost,  and  little  or  no  shock  was  induced."  This  patient 

26* 


306  SURGERY   OF   THE   CRIMEAN    WAR. 

was  seized  with  rigors,  and  died  of  exhaustion  011  the  night 
of  the  21st,  i.e.  on  the  fifteenth  day  from  being  wounded. 
The  internal  viscera  do  not  seem  to  have  been  examined  ; 
but,  as  to  the  state  of  the  femur,  Dr.  Crerar  says  "nature 
had  not  made  the  slightest  attempt  to  repair  the  loss." 

The  next  case,  which  was  the  only  one  where  success  fol- 
lowed the  operation,  was  that  of  private  Thomas  Mackenena 
of  the  68th  Light  Infantry,  operated  on  by  Mr.  O'Leary, 
surgeon  of  that  regiment.  The  age  of  the  patient  was  25  ; 
and  he  was  wounded  on  the  19th  of  August,  by  a  fragment 
of  shell  which  struck  him  over  the  great  trochanter  and 
fractured  it.  It  was  thought  that  the  fracture  ran  into  the 
joint — a  supposition  which  was  disproved  at  the  operation, 
as  the  head  of  the  bone  was  uninjured.  Five  inches  were 
in  all  removed.  After  operation,  the  limb  was  slung  to  the 
beam  of  the  hut.  This  patient  recovered  in  three  months. 
I  have  lately  heard  of  this  man  through  the  kindness  of 
Lieut. -Col.  Stuart,  commanding  the  pensioners  in  the  Newry 
district.  Dr.  Shaw,  who  signs  the  report,  states  that  "the 
limb  is  two  inches  shorter  than  the  corresponding  one,  and 
also  considerably  smaller ;  extension  can  be  carried  on  par- 
tially, but  he  cannot  flex  the  limb  upon  the  thigh  without 
placing  his  hand  on  the  glutei  muscles  of  the  diseased  side. 
Rotation,  inward  and  outward,  can  be  performed  only  to  a 
limited  extent.  The  wound  over  the  joint  is  quite  healed. 
The  man's  general  health  is  good,  but  he  cannot  walk  with- 
out the  assistance  of  crutches." 

Dr.  Hyde  operated  on  another  case,  after  the  taking  of 
the  fortress.  His  patient,  a  private  of  the  41st,  had  the 
neck  of  the  bone  severely  comminuted  by  a  grape-shot,  and 
died  on  the  fifth  day  after  operation.  The  cause  of  death  is 
not  given,  nor  can  I  discover  it  from  the  report  of  the  case. 

Dr.  Combe,  of  the  Royal  Artillery,  performed  the  sixth 
and  last  operation,  on  account  of  a  gunshot  wound  of  the 
neck  of  the  femur,  in  which,  however,  the  head  of  the  bone 
was  not  implicated.  This  operation  was  not  a  primary  one, 


GUNSHOT   WOUNDS  OF   JOINTS.  301 

hu t  the  patient  survived  a  fortnight,  and  died  of  exhaustion, 
the  most  marked  feature  in  the  case  being  that  the  pulse 
remained  very  high — never  below  120 — during  the  period 
he  lived,  while  his  aspect  was  calm,  and  such  as  "might 
have  led  one  to  expect  a  more  subdued  state  of  the  circu- 
lation." 

Death  thus  followed  in  2  (1  ?)  from  exhaustion,  in  1  (2  ?) 
from  pyrcmia,  in  1  from  cholera,  and  in  1  from  a  cause  that 
is  unknown. 

It  is  a  remarkable  fact  that  in  these  cases  the  head  of  the 
bone  so  often  escaped,  when  the  upper  part  of  the  shaft  was 
fractured  in  pieces,  which  is  probably  to  be  accounted  for 
by  its  protected  position,  and  perhaps  by  the  same  cause  as 
that  before  mentioned  with  reference  to  the  head  of  the  hu- 
merus,  viz.,  the  non-extension  of  fracture  of  the  shaft  to  the 
epiphysis. 

Boyer  and  others  have  dwelt  upon  the  depth  of  the  parts, 
the  strong  ligaments,  the  difficulty  of  turning  out  the  head 
of  the  bone,  etc.,  as  insuperable  objections  to  this  operation  ; 
but  actual  experience — both  in  civil  practice,  where  it  has 
recently  been  so  often  performed  for  disease,  and  especially 
in  our  attempts  in  the  Crimea,  where  the  soft  parts  were  in 
their  natural  condition,  and  the  difficulty  of  turning  out  the 
head  of  the  bone  increased  by  the  broken  state  of  the  shaft 
— proves  that  there  is  no  such  barriers  to  its  easy  execution. 
The  greatest  difficulty  lies  in  the  after-treatment.  It  is  de- 
sirable to  fix  the  parts  thoroughly,  and  at  the  same  time  to 
allow  of  some  change  of  position.  Mr.  O'Leary  managed 
this  to  some  extent  by  means  of  a  canvas  sling  for  the  limb. 
The  fixture  cannot,  however,  be  satisfactorily  accomplished 
in  this  way,  whatever  power  it  gives  of  changing  the  posi- 
tion of  the  patient.  I  adopted  the  inclined  plane  in  pref- 
erence to  the  long  splint,  because  I  believe  the  position  to 
be  an  easier  one  for  such  a  case,  and  also  because  it  permit- 
ted the  free  discharge  of  the  pus  and  the  easy  dressing  of 
the  wound  without  disturbing  the  patient.  If  the  idea  lately 


308  SURGERY   OF   THE    CRIMEAN   WAR. 

suggested  at  King's  College,  of  slinging  the  whole  body, 
could  be  carried  out,  it  might  afford  many  advantages  in  the 
management  of  excisions  of  the  hip.  As  to  keeping  the 
limb  in  a  good  position  during  cure,  I  fear  more  important 
ends  are  lost  sight  of  in  striving  after  it.  The  uneasiness 
and  irritation  which  the  splints  and  rollers  give  do  much  to 
prevent  success.  It  matters  little  what  the  resulting  length 
of  the  limb  proves  to  be,  if  the  patient's  life  is  saved  ;  nor 
does  it  greatly  matter  that  it  be  somewhat  out  of  the  right 
axis. 

As  to  the  comparative  advantages  of  amputation  and 
excision  at  the  hip  in  cases  of  compound  fractures  of  the 
head  and  neck  of  the  femur  by  gunshot,  some  hint  may  be 
got  from  our  experience  in  the  Crimea.  Out  of  twenty- 
three  cases  of  amputation  which  took  place,  either  in  our 
army  or  in  that  of  the  French,  not  one  recovered ;  and 
nearly  all  died  miserably,  very  shortly  after  operation.  All 
those,  on  the  other  hand,  on  whom  excision  was  practiced, 
lived  in  comparative  comfort,  all  without  pain,  for  a  con- 
siderable time.  Out  of  six  operated  on  one  survived  for 
more  than  a  month,  one  died  from  causes  unconnected  with 
the  operation,  and  one  case  recovered  entirely.  The  chance 
of  saving  life  is  thus  manifestly  on  the  side  of  excision,  and 
this  is  truly  the  most  important  aspect  of  the  question.  The 
objection  so  often  advanced  to  the  operation,  that  the  limb 
resulting  from  excision  is  useless,  even  if  true,  has  nothing 
to  do  with  the  matter.  It  is  a  question  of  deeper  and  more 
serious  bearing  than  such  an  objection  would  imply.  The 
only  point  worthy  of  discussion  is,  which  operation  holds 
out  the  best  chance  of  preserving  life  ?  The  little  light  de- 
rived from  our  Crimean  experience  is  quite  conclusive,  so 
far  as  it  goes.  In  the  one  case  a  life  was  saved,  while,  out 
of  four  times  as  many  cases  of  the  other  operation,  not  one 
survived.  It  is  true  that  many  cases  submitted  to  amputa- 
tion may  have  undergone  more  extensive  injury  than  any 
of  those  excised,  and  it  is  also  true  that  one  case  of  exarticu- 


GUNSHOT    WOUNDS   OF   JOINTS.  309 

latiou  did,  to  all  intents  and  purposes,  recover;  yet  the 
shock  of  excision  must  be  much  less  than  that  of  amputa- 
tion, seeing  that  the  great  vessels  and  nerves  are  not  touched, 
and  that  those  changes  in  the  blood  of  the  limb  are  not  in- 
terrupted, which  some  authorities  contend  is  the  cause  of 
death  after  amputation.  In  all  the  cases  of  excision  the 
loss  of  blood  was  trifling  —  a  matter  of  much  moment  with 
patients  like  ours  —  and  the  immediate  relief  from  pain  and 
irritation  was  very  marked  in  all  the  cases. 

Gunshot  wounds  of  the  hip-joint  are  in  many  instances 
particularly  adapted  for  resection,  the  injury  of  the  bone  being 
often  limited,  and  the  soft  parts  but  little  destroyed.  There 
are,  on  the  other  hand,  few  accidents  which  present  these 
conditions  in  civil  life.  When  the  shaft  of  the  femur  is  split 
below  the  trochanter  major,  excision  is  hardly  applicable, 
although  Seutin  performed  it  when  he  had  six  inches  of  the 
shaft  to  remove. 

Seutin,  Oppenheim,  and  Schwartz  have  all  excised  the 
hip  for  gunshot  injuries,  but  not  with  success,  although  all 
seem  to  have  been  impressed  with  its  feasibility.  Paillard 
gives  an  account  of  Seutin's  case,  from  which  it  would  ap- 
pear that  the  patient  sank  on  the  ninth  day  from  gangrene. 
Six  inches  of  the  bone  were  removed  in  this  case.  In  Op- 
penheim's  case,  the  bone  was  removed  as  low  down  as  the 
little  trochanter,  and  the  patient  lived  eighteen  days.  Es- 
march  relates  Schwartz's  case.  It  was  a  secondary  opera- 
tion. The  bone,  "to  two  inches  below  th«  small  trochanter," 
was  removed.  He  died  of  pyaemia  on  the  seventh  day  after 
operation.  Esmarch  refers  to  another  case,  operated  on 
by  Dr.  lloss,  and  related  in  the  forty-first  number  of  the 
Deutsches  Klinik,  1850,  which  ended  similarly.  This  last 
operation  was  performed  two  years  after  injury. 

For  disease,  excision  of  the  head  of  the  femur  has  been 
now  often  performed,*  and  many  times  with  success  ;  the 


*  Dr.  Say  re,  in  the  New  York  Journal  of  Medicine,  January, 
after  relating  a  case  of  excision  for  morbus  coxae,  gives  a  summary 


310  SURGERY   OF   THE   CRIMEAN   WAR. 

very  great  difference,  however,  that  exists  between  the  opera- 
tion as  performed  for  disease  and  for  accident,  prevents  any 
comparison  being  made  between  their  results. 

Much  might  have  been  done,  if  we  had  had  another  cam- 
paign, to  determine  the  exact  value  of  excision,  as  applied 
to  gunshot  wounds  of  the  hip-joint.  If  the  cases  were 
selected  with  care,  and  the  operation  early  performed,  before 
the  vital  powers  began  to  flag,  and  if  the  after-treatment 
were  carefully  conducted,  much  might  be  expected  from  this 
operation  in  military  practice.  It  is  often  very  difficult  to 
tell  how  far  the  destruction  of  the  bone  extends,  either  up- 
ward or  downward ;  but  if  the  case  should  turn  out  to  be 
too  complicated  for  excision,  then  amputation  may  be  per- 
formed. Stromeyer  has  shown  that,  although  the  splitting 
of  the  bone  barely  extends  into  the  capsule  —  as  it  did 
in  my  case — yet  excision  should  be  at  once  performed,  as 
suppuration  is  sure  to  be  set  up  in  the  articulation,  and 
death  by  exhaustion  follow.  The  same  surgeon  has  also 
shown  how  it  happens  that,  although  the  neck  of  the 
bone  be  fractured  by  a  ball,  yet  the  usual  signs  of  such 
an  injury — the  shortening  and  rotation  of  the  foot — may 
be  absent,  from  "  the  fragments  hanging  together  better 
on  account  of  the  partial  preservation  of  their  fibrous  cov- 
ering," and,  in  one  case  which  he  examined,  a  considera- 
ble power  of  flexion  and  extension  remained,  although  the 
neck  of  the  bone  was  fractured ;  while,  in  another  case, 
"  the  fragments  fitted  so  well  together  that  the  patient  did 
not  experience  the  least  pain,  and  the  leg  could  be  moved 
without  causing  crepitation."  The  existence  of  the  fracture 
was  only  determined  in  this  case  by  the  presence  of  a  pro- 
fuse discharge.  The  patient  himself  may  even  be  able  to 


of  the  operations  of  this  sort  performed  up  to  that  time.  I  need 
hardly  add,  that  many  have  been  performed  since  Dr.  Sayre  wrote. 
He  classifies  80  cases,  of  whom  20  recovered  and  10  died,  only  4, 
however,  within  a  week  of  the  operation. 


GUNSHOT   WOUNDS   OF   JOINTS.  811 

move  his  foot,  and  so  mask  the  diagnosis.  Esmarch  gives 
"the  extensive  swelling  occurring  rapidly,  and  the  pain  on 
motion,"  as  the  only  two  signs  which  are  nearly  always 
present. 

It  need  hardly  be  added,  that  if,  in  fracturing  the  neck  of 
the  bone,  the  ball  or  any  of  the  osseous  fragments  injure  the 
great  blood-vessels,  the  case  is  not  one  for  excision. 

The  knee  was  only  once  excised,  so  far  as  I  know,  during 
the  war.  The  operation  was  performed  in  the  general 
hospital  by  Mr.  Lakin,  whose  notes  of  the  case  have  been 
kindly  furnished  to  me. 

"Henry  Gribben,  aged  19,  a  private  in  the  77th  Regi- 
ment, was  admitted  into  the  general  hospital  on  September 
8th,  1855.  While  retreating  from  the  Redan  on  that  day, 
he  received  a  musket-ball  in  his  left  popliteal  space,  causing 
him  much  difficulty  in  walking ;  nevertheless,  he  succeeded 
in  regaining  the  advanced  trenches,  distant  about  100  yards. 
He  was  a  man  of  average  muscular  development,  and  of 
habitually  good  health.  On  admission,  a  circular  wound, 
with  inverted  edges,  was  found  at  the  inner  part  of  the 
popliteal  space,  and  at  the  level  of  the  junction  of  the  upper 
and  middle  thirds  of  that  space.  It  was  of  a  diameter  just 
sufficient  to  admit  the  index  finger,  which  could  be  passed  to 
its  full  length  in  a  direction  forward,  and  slightly  upward, 
between  the  inner  hamstring  tendons.  No  fracture  nor  other 
injury  of  the  bone  was  detected,  neither  could  the  further 
course  of  the  ball  be  ascertained  by  means  of  a  probe  or 
elastic  catheter.  It  was  not  considered  prudent  to  use  much 
force  with  these  instruments,  in  consequence  of  the  close 
proximity  to  the  joint,  and  of  the  absence  of  any  satisfactory 
evidence  that  its  cavity  was  already  opened.  There  was  no 
aperture  of  exit,  the  limb  was  not  altered  in  shape  ;  flexion 
and  extension,  especially  the  former,  were  limited,  and  any 
attempt  to  move  the  limb  beyond  these  limits  was  attended 
with  much  pain,  which  was  otherwise  slight.  Simply  bear- 
ing the  weight  of  the  body  only  caused  some  uneasiness,  and 


312  SURGERY    OF    THE    CRIMEAN    WAR. 

there  was  no  tenderness  on  pressure  from  without.  There 
was  no  appearance  of  synovia  about  the  wound,  nor  was 
there  any  bleeding.  Under  these  circumstances  it  was  con. 
sidered  that  any  operative  measures  for  the  purpose  of 
removing  the  ball  were  not  justifiable." 

The  limb  was  placed  upon  its  outer  side,  with  the  knee 
semiflexed,  that  being  found  the  most  agreeable  posture,  and 
cold  dressing  was  applied.  The  patient  remained  almost 
free  from  pain,  except  when  the  limb  was  moved,  and  in 
good  health,  until  September  20th,  twelve  days  after  the 
injury,  when  the  joint  became  somewhat  inflamed,  as  in- 
dicated by  increased  pain  and  heat,  slight  tenderness  to 
pressure,  and  moderate  swelling.  Twelve  leeches  and  hot 
fomentations  were  applied,  and  afforded  great  relief.  The 
symptoms  subsided,  and  remained  in  abeyance  till  about  the 
29th,  when  they  gradually  increased,  the  joint  becoming 
much  swollen  and  tender,  the  veins  more  distinctly  visible, 
and  the  general  health  beginning  to  suffer  for  the  first  time, 
as  evinced  by  slight  perspirations,  debility,  frequent  pulse, 
loss  of  appetite,  thirst,  disturbed  rest,  etc.  The  swelling  of 
the  joint  was  uniform,  and  no  fluctuation  could  be  perceived 
in  it,  though  it  was  thought  that  there  was  some  deep-seated 
fluctuation  about  three  inches  above  the  joint,  on  the  outer 
side  of  the  thigh. 

"  It  was  decided  in  consultation  to  examine  the  limb  while 
the  patient  was  under  the  influence  of  chloroform,  and  then 
to  adopt  such  measures  as  the  examination  might  indicate ; 
accordingly,  on  October  1st,  he  was  placed  upon  the  oper- 
ating table,  and  chloroform  administered.  With  some  diffi- 
culty, and  by  using  considerable  force,  the  finger  could  feel 
a  part  of  the  head  of  the  tibia,  bare  and  rough,  a  small  piece 
of  bone  having  been  chipped  off  its  inner  and  posterior  edge, 
but  the  site  of  the  ball  was  not  detected,  though  it  was 
thought  to  be  in  the  joint,  possibly  in  the  space  between  the 
condyles  of  the  femur.  It  was  then  decided  to  make  such 
an  incision  as  would  admit  of  the  performance  of  either  ex- 


GUNSHOT    WOUNDS    OF    JOINTS.  313 

cision  or  amputation,  whichever  proceeding  the  condition  of 
the  parts  might  indicate.  This  was  accordingly  done  ;  and 
on  opening  the  joint  several  portions  of  the  cartilage  cover- 
ing both  bones  were  found  to  be  partially  detached  from  the 
bone,  softened,  and  their  surface  eroded.  No  fracture  was 
found,  except  the  small  piece  chipped  off  the  inner  and 
posterior  edge  of  the  head  of  the  tibia." 

"Excision  being  now  decided  on,  and  as  the  necessary 
steps  were  being  taken,  pus  escaped  from  a  cavity  which 
existed  in  the  outer  side  of  the  thigh,  and  partially  surround- 
ing the  femur.  The  ball  was  found  to  have  penetrated  the 
inner  condyle.  About  an  inch  and  three-quarters  of  the 
femur  was  removed,  as  well  as  a  thin  slice  of  the  head  of  the 
tibia.  The  patella  was  also  dissected  out,  because  portions 
of  its  cartilage  were  softened,  and  partially  detached.  The 
slight  oozing  of  blood  was  soon  stopped  by  cold  water." 
No  vessel  required  a  ligature.  The  edges  of  the  wound 
were  brought  together,  and  retained  by  sutures  and  strap- 
ping. The  extremities  of  the  incision  were  left  open,  to 
allow  of  the  escape  of  pus,  etc.  Wet  lint  was  applied,  and 
the  limb  placed  in  a  straight  position  on  a  M'Intyre's  splint, 
with  a  short  whalebone  splint  on  each  side  of  the  joint, 
secured  by  strap  and  buckles.  The  patient  was  placed  in 
bed,  and  a  grain  of  morphia  given  him. 

"  The  portion  of  femur  removed  was  about  one  and  three- 
quarter  inches  long,  and  presented  an  ordinary  round  musket- 
bullet,  about  half  imbedded  in  the  inner  condyle,  the  bone 
not  being  split,  but  the  joint  opened." 

No  symptom  arose  calling  for  remark  up  to  the  25th, 
when  Mr.  Lakin's  report  runs  thus :  "  Had  continued  slowly 
improving  and  gaining  strength  until  to-day  ;  the  discharge 
had  diminished  in  quantity.  Had  not  accumulated  nor 
bagged.  The  limb  had  acquired  slight  firmness.  The 
wound  looked  healthy,  and  had  nearly  healed  across  the 
front.  Some  difficulty  had  been  found  in  keeping  it  in  very 
accurate  position,  as  he  twisted  about  when  using  the  bed- 

27 


314  SURGERY    OF    THE    CRIMEAN    WAR. 

pan,  and  he  is  naturally  a  reckless,  troublesome  fellow.  His 
bowels  were  occasionally  slightly  relaxed,  but  this  was  soon 
relieved  by  a  dose  of  the  aromatic  mixture.  To-day  he  seems 
progressing  favorably,  but  has  got  his  limb  into  a  bad  posi- 
tion ;  bent  so  as  to  form  an  angle  externally.  A  slight  dis- 
colored patch,  as  of  a  commencing  slough,  on  the  outer  side 
of  the  limb,  corresponding  to  the  position  of  the  displaced 
end  of  the  femur,  at  the  upper  extremity  of  the  wound. 
The  plane  is  readjusted,  and  the  limb  secured  to  it  by  band- 
ages. The  discharge  is  again  rather  increased  in  quantity. 
A  bad  sore  had  formed  upon  the  sacrum,  but  is  improving 
under  treatment." 

Again,  on  the  2Tth,  the  report  says:  "Complains  rather 
of  chilliness  this  morning,  but  has  had  no  rigors.  Has 
vomited  several  times,  and  his  bowels  have  been  purged. 
Pulse  110.  Tongue  moist  and  clean,  wound  healthy,  small 
slough  on  outer  side  not  extending,  discharge  us  usual,  urine 
drawn  by  a  catheter." 

The  diarrhoea,  although  temporarily  checked  by  treatment, 
went  on,  and  the  sickness  greatly  prostrated  his  strength. 
Mr.  Lakin  notes  as  follows  on  the  28th  :  "  Rapidly  getting 
worse.  Pulse  130.  Yery  low  ;  evidently  sinking  ;  counte- 
nance much  altered,  but  simply  looking  sunken  and  pale,  and 
not  having  the  peculiar  aspect  of  pyaemia.  Died  at  night." 

Post  mortem  14  hours  after  death.  "Before  removing 
the  body  to  the  'dead  tent,'  the  orderlies  had  taken  off  the 
splint,  and  the  limb  had  been  allowed  to  hang  down,  so  as 
to  destroy  any  points  of  union  that  there  might  have  been. 
The  wound  had  healed,  except  its  extremities,  the  granula- 
tions on  which  had  shrunk  and  assumed  a  black  appearance, 
(post  mortem  ;)  the  opposed  surfaces  of  the  bones  presented 
a  very  similar  appearance,  and  there  was  no  sign  of  dead 
bone.  They  had  become  moulded  to  one  another  in  shape. 
Whether  there  had  been  any  union  toward  the  center  was 
not  evident ;  at  the  circumference  there  were  appearances  of 
some  adhesions  having  been  broken.  The  cavity  of  the  joint 


GUNSHOT   WOUNDS   OF   JOINTS.  315 

contained' only  a  small  quantity  of  pus.  The  abscess  in  the 
outer  part  of  the  thigh  had  almost  healed.  No  purulent 
deposits  could  be  found  in  any  of  the  organs,  nor  could  any 
appearance  of  phlebitis  be  detected.  The  viscera  were 
healthy." 

"I  ascertained,"  adds  Mr.  Lakin,  "after  his  death,  that, 
on  the  2Gth  and  27th,  he  had  eaten  some  apples  which  he 
had  bought,  and  that  the  vomiting  and  diarrhoea  came  on 
after  that.  He  had  not  at  all  the  appearance  of  a  man  suf- 
fering from  pyteinia,  but  seemed  simply  to  die  exhausted  by 
sickness  and  diarrhoea. " 

"  The  opening  through  which  the  bullet  entered  remained 
patent  all  the  time,  and  a  great  deal  of  the  discharge  escaped 
through  it ;  though  probably  the  two  extremities  of  the  in- 
cision would  have  been  sufficiently  ou  the  posterior  part  of 
the  limb  to  prevent  the  matter  from  bagging." 

Admiring  as  I  do  the  brave  attempts  which  have  been 
made  in  civil  practice  to  save  limbs  by  excising  the  knee,  I 
regret  that  it  should  not  also  be  extended  to  military  prac- 
tice ;  but  except  in  rare  circumstances,  I  fear  that  cannot  be 
accomplished,  from  the  careful  after-treatment  and  the  long 
period  of  convalescence  necessary  to  effect  a  cure.  Ferguson 
speaks  of  more  than  100  cases  having  been  now  operated  on 
in  civil  practice,  and  Butcher  has  shown  that  the  mortality 
is  greatly  less  than  what  succeeds  amputation  of  the  thigh  ; 
but  it  is  to  be  remembered  that  these  cases  were  of  an  age 
and  a  history  which  rendered  the  procedure  much  more  hope- 
ful than  it  almost  ever  can  be  in  warfare.  A  diseased  joint 
is  a  constant  source  of  irritation  and  depression  to  the  con- 
stitution, so  that,  in  the  words  of  Sir  Philip  Crampton,  "by 
its  total  excision  all  those  parts  which  were  diseased,  and 
influenced  the  constitution  so  unfavorably,  are  removed  from 
the  system,  and  the  injury  is  resolved  into  a  case  of  clean 
incised  wound,  with  a  divided  but  not  fractured  or  diseased 
bone  at  the  bottom  of  it,"  and  thus  the  powers  of  the  system 
which  went  to  feed  the  disease  are  already  so  diverted  to  the 


316  SURGERY    OF    THE    CRIMEAN    WAR. 

part  as  to  build  up  the  loss,  so  soon  as  they  can  work  on 
a  proper  material.  That  nice  adaptation,  however,  of  the 
surfaces,  that  accurate  fixture  of  the  limb,  the  careful  atten- 
tion, nourishment,  and  perfect  repose  which  such  cases  ob- 
tain in  a  civil  hospital,  and  which  have  so  much  to  do  with 
the  result,  can  hardly  be  attained  in  the  field.  Mr.  Ferguson, 
in  the  last  edition  of  his  admirable  manual,  thus  sums  up  the 
advantages  which  his  large  experience  ascribes  to  the  oper- 
ation :  "The  wound  is  less  than  in  amputation  of  the  thigh, 
the  bleeding  seldom  requires  more  than  one  or  two  ligatures, 
the  loss  of  substance  is  less,  and  probably  on  that  account 
there  is  less  shock  to  the  system  ;  the  chances  of  secondary 
hemorrhage  are  scarcely  worth  notice,  as  the  main  artery  is 
left  untouched  ;  there  is,  in  short,  nothing  in  the  after-con- 
sequences more  likely  to  endanger  the  patient's  safety  than 
after  amputation,  while  the  prospect  of  retaining  a  useful 
and  substantial  limb  should  encourage  both  patient  and 
surgeon  to  this  practice." 

If  the  operation  be  performed  in  the  field,  the  sooner  it  is 
undertaken  the  better;  for,  although  primarily  free  of  disease, 
the  articulation  soon  becomes  affected,  if  it  be  left  a  prey  to 
inflammation  and  abscess ;  the  constitution  rapidly  sympa- 
thizes, and  that  blood-poisoning  which  is  so  liable  to  follow 
may  be  established  before  we  well  see  the  danger  of  delay. 
Secondary  operations,  too,  it  should  always  be  remembered, 
do  not  hold  out  the  same  prospect  of  success  in  military  as 
they  do  in  civil  practice. 

The  saving  of  blood,  and  the  absence  of  any  fear  of 
secondary  hemorrhage  which  has  been  pointed  out  by 
Butcher  and  Ferguson,  are  points  of  much  weight  in  favor 
of  resection  when  patients  are  to  be  dealt  with  who  are  so 
sensitive  to  any  hemorrhages  as  those  we  had  to  deal  with 
i  n  the  Crimea. 

The  resection  of  parts  of  the  shafts  of  the  long  bones 
was  not,  to  my  knowledge,  much  practiced  in  the  Crimea. 
The  lengthened  period  those  cases  take  to  recover,  and  the 


GUNSHOT    WOUNDS   OF   JOINTS.  3iT 

trying  nature  of  this  ordeal  ou  the  vitul  powers,  made  such 
abstinence  with  us  almost  a  necessity.  Several  cases  resulted 
very  favorably,  in  which  part  of  the  shafts  of  the  hunierus,  of 
the  bones  of  the  forearm,  and  of  the  leg,  were  thus  dealt 
with ;  but  in  more  than  one  case  in  which  I  knew  such  steps 
taken,  too  much  was  expected  of  the  reparative  powers  of 
our  patients,  too  large  an  extent  of  the  bone  was  removed, 
and  thus  the  operation  failed.  It  was  toward  the  end  of  the 
war  that  the  best  results  were  obtained  from  these  resections. 
In  the  case  of  the  tibia  especially  the  choice  between  ampu- 
tation and  resection  must  be  guided  chiefly  by  a  consider- 
ation of  the  state  of  health  of  the  patient,  whether  or  not 
he  is  in  a  condition  to  withstand  a  long  and  tedious  cure  ; 
by  the  extent  of  destruction  of  the  bone,  and  especially  of 
its  periosteum  ;  and,  finally,  the  means  at  hand  for  carrying 
out  the  after-treatment. 

Resections  in  the  continuity  of  the  femur  were,  so  far 
as  I  know,  invariably  fatal.  The  difficulty  of  the  operation 
on  muscular  limbs  must  of  itself  predispose  to  disagreeable 
results.*  False  joints  are,  as  is  well  known,  apt  to  occur 
after  resection  in  the  continuity  of  bones  of  the  leg  and  fore- 
arm, when  the  operation  is  practiced  on  only  one  of  their 
two  bones. 

*  The  success  of  two  cases  lately  published  by  Mr.  Jones,  of  Jer- 
sey, in  which  a  considerable  part  of  the  shaft  of  the  femur  was 
removed,  shows  that  these  operations  may  be  well  adopted  in  civil 
practice  at  any  rate. 


27* 


CHAPTER  XII. 

AMPUTATIONS. 

THE  relative  advantage  of  primary  and  secondary  am- 
putation has  always  held  the  first  place  among  the  various 
problems  which  the  army  surgeon  has  had  to  solve.  With 
all  that  has  been  written  on  the  subject  by  military  and  civil 
surgeons,  there  still  seems  considerable  reluctance  to  accept 
the  question  as  settled.  The  discrepancy  of  evidence 
brought  to  bear  on  the  subject  has  chiefly  arisen  from  the 
evident  distinction  being  overlooked  between  operations 
undertaken  for  accident  and  for  disease.  Civil  hospitals 
can  seldom  afford  testimony  similar  to  that  obtained  from 
the  field  of  battle,  and  thus  it  happens  that  civil  surgeons 
have  come  to  stand  in  some  measure  in  apparent  antagonism 
to  their  military  brethren  on  the  point  of  practise  under 
consideration.  Hunter  was  so  much  of  the  civilian  as  to 
adhere  to  consecutive  operation,  although,  with  very  few 
exceptions,  surgeons  who  have  practiced  in  armies  have 
strongly  advocated  early  interference  since  the  days  of 
Duchesne  and  Wiseman.*  The  difference  which  so  mani- 

*  Hunter  surely  does  not  express  the  opinion  of  military  surgeons, 
•with  perhaps  the  exception  of  Faure,  when  he  says:  "I  believe  it 
is  universally  allowed  by  those  whom  we  are  to  esteem  the  best 
judges,  those  who  have  had  opportunities  of  making  comparative 
observations  on  men  who  have  been  wounded  in  the  same  battle, 
some  where  amputation  had  been  performed  immediately,  and  others 
where  it  had  been  left  till  all  circumstances  favored  the  operation ;  it 
has  been  found,  I  say,  that  few  did  well  who  had  their  limbs  cut  off 
on  the  field  of  battle,  while  a  much  greater  proportion  havo  done 
well,  in  similar  cases,  who  were  allowed  to  go  on  till  the  first  inflam- 
(318) 


AMPUTATIONS.  319 

festly  exists  between  the  moral  condition  of  the  patients  who 
are  operated  on  for  accident  in  civil  life,  and  the  soldier  in 
the  field,  together  with  the  circumstances  in  which  each  is 
treated  after  operation,  introduce  so  many  different  items 
into  the  calculation  of  the  question  of  amputation,  that  it  is 
almost  impossible  to  make  use  of  the  experience  of  either 
sphere  to  illustrate  or  influence  that  of  the  other.  Besides 
this,  the  severity  of  those  injuries  which  present  themselves 
in  military  practice,  and  which  authorize  the  removal  of  the 
limb,  is  so  great  that  it  is  but  reasonable  to  suppose  that 
an  operation  which  removes  so  vast  a  source  of  irritation 
and  pain  at  the  earliest  moment  possible,  must  promise  the 
best  results  in  saving  the  life.  In  short,  military  experience 
on  this  point  must  regulate  military  practice,  and  the  results 
of  civil  experience  must  continue  to  regulate  civil  practice. 

To  military  surgeons  the  question  of  primary  or  second- 
ary amputation  is  a  settled  one.  The  experience  of  every 
war  has  more  and  more  confirmed  the  advantages  of  early 
operation,  and  that  in  the  Crimea  has  not  disturbed  the 
rule ;  in  fact,  later  observation  would  lead  us  to  go  further, 
and  in  place  of  merely  advocating  interference  within  twenty- 
four  hours,  the  prevailing  idea  at  present  would  be  better 
expressed  by  saying  that  every  hour  "the  humane  operation" 
is  delayed  diminishes  the  chances  of  a  favorable  issue. 

It  is  impossible  to  prove  from  any  returns  the  full  bearing 
of  this  question,  as  the  mere  number  who  survived  after  a 
given  number  of  operations  performed  primarily  or  second- 
arily by  no  means  expresses  the  terms  of  the  question.  It 
would  manifestly  be  necessary  to  know  how  many  died 

mation  was  over,  and  underwent  amputation  afterward  "  Contra -t 
Hiich  sentiments  with  the  immense  mass  of  facts  scattered  throughout 
the  works  of  Larrey,  Guthrie,  Hennen,  and,  in  fact,  of  every  mili- 
tary surgeon  who  has  published  his  experience  in  this  or  foreign 
countries  for  many  years,  and  then  let  us  be  led,  in  estimating  this 
long- contested  question,  by  what  Hunter  s-<\ys  is  "the  best  guide," 
vi/.,  experience. 


320          SURGERY  OF  THE  CRIMEAN  WAR. 

before  the  secondary  period  came  round,  and  to  these 
should  be  added  the  victims  of  delayed  interference,  with 
all  the  pain  and  suffering  which  such  delay  occasioned, 
before  we  can  arrive  at  a  just  estimate  of  the  results  of 
either  proceeding.  The  experience  in  the  Crimea  in  favor 
of  early  operation  was  unequivocal  in  both  armies,  and 
needs  no  illustration  from  me.* 

Chloroform  has  done  much  to  render  the  success  of 
primary  amputation,  as  contrasted  with  secondary,  yet  more 
marked.  If  we  believe,  as  I  certainly  do,  that  by  the  use  of 
this  anesthetic  all  fear  of  intensifying  the  shock  is  obviated 
— which  was  one  reason  why  surgeons  delayed  operation — 
then  the  tendency  of  military  surgery,  since  the  introduction 
of  chloroform,  must  be  to  still  earlier  and  more  prompt 
interference. 

Secondary  amputations  were  much  more  common  during 
the  early  than  the  late  period  of  the  war — a  circumstance 
which  arose  from  the  deficient  means  of  treating  the 
wounded  in  the  camp  during  the  former  as  compared  with 
the  latter  period,  and  thus  the  necessity  that  existed  of 
dispatching  them  from  camp  immediately  after  being  in- 
jured ;  and  this,  together  with  the  better  hygienic  condition 
of  the  patients  toward  the  end  of  the  war,  accounts  for  a 
fact,  well  known  to  those  who  served  in  the  East,  but  which 
the  range  of  the  returns  does  not  enable  me  to  show  in 
figures,  that  amputations  were  much  more  successful,  as  a 
whole,  toward  the  conclusion  than  at  the  outset  of  the  war. 
At  first,  too,  when  patients  were  early  sent  from  camp,  not 
a  few  operations,  to  my  own  knowledge,  were  performed 
during  the  "  intermediary"  period,  and,  without  one  excep- 
tion, those  thus  falling  within  my  observation  were  fatal. 

The  tremendous  destruction  which  was  at  times  occa- 


*  I  am  led  to  understand,  from  a  very  well-informed  source,  that 
the  Russians  also  lost  two-thirds  of  all  their  secondary  operations, 
but  saved  a  fair  number  of  their  primary. 


AMPUTATIONS.  321 

sioned  by  round  shot  or  shell  left  little  hope  from  any 
operation  whatever.  In  the  case  of  many,  a  pansement  de 
consolation  was  the  only  alternative,  while,  in  not  a  few, 
the  injury  was  so  severe  that,  although  amputation  was 
performed,  in  the  vain  hope  of  a  possible  success,  yet  the 
apparent  advantage  of  primary  operation  thereby  suffered, 
and  this  circumstance  is  another  of  the  many  which  makes 
it  impossible  to  place  this  question  in  a  fair  light.  The 
most  severely  injured  have  their  limbs  removed  early,  while 
the  most  hopeful  are  retained  for  secondary  operation,  and 
thus  all  the  advantages  of  slighter  injury — less  constitutional 
disturbance,  more  promising  habit  of  body,  and  state  of 
general  health  —  are  denied  to  the  early  operations.  In 
truth  it  may  be  said  that  if,  with  all  the  advantages  under 
which  secondary  amputations  are  recorded,  they  appeared 
as  merely  equal  in  success  to  primary,  then  the  superior 
claims  of  the  latter  to  our  attention  would  be  sufficiently 
clear;  how  much  more  marked,  then,  are  the  successes  of 
early  operations,  when  we  find  them  giving  such  superior 
results  1 

As  to  the  general  success  of  amputations,  during  the  late 
war,  it  may  be  safely  said  that,  when  due  weight  is  given  to 
the  many  circumstances  which  have  militated  against  the 
success  of  all  operations,  and  which  have  been  fully  dwelt 
upon  in  the  course  of  the  preceding  pages,  those  performed 
early  have  afforded  a  very  fair  proportion  of  success;  while 
it  cannot  be  denied  but  that  those  undertaken  late  have 
been  followed  by  most  unfortunate  results. 

A  siege  presents  peculiarly  favorable  opportunities  for 
testing  the  value  of  immediate  amputations.  The  men 
being  close  together,  and  acting  within  a  narrow  space, 
can  be  seen  almost  instantly  on  being  injured.  The  position 
of  the  soldier  in  such  circumstances  resembles  that  of  the 
sailor  on  board  of  his  ship;  so  that  the  experience  of  naval 
surgeons,  which  is  so  strongly  in  favor  of  instant  amputa- 
tion, applies  with  peculiar  force  to  military  siege  practice. 


322  SURGERY   OF   THE   CRIMEAN    WAR. 

Unfortunately,  the  arrangement  followed  in  our  army  during 
the  siege  of  Sebastopol  made  the  elucidation  of  this  point 
impossible.  Assistant-surgeons  were  alone  sent  to  the 
trenches,  (except  during  an  assault,  when  a  staff-surgeon 
occupied  one  of  the  ravines  behind  each  division  ;  but  in  the 
hurry  and  confusion  which  prevailed  at  such  times,  the  men 
he  operated  on  were  lost  sight  of;)  and  as  by  the  rules 
which  prevail  in  our  service,  an  officer  of  that  rank  is  not 
allowed  to  amputate,  except  when  the  surgeon  is  not  with 
the  regiment,  no  means  existed  for  the  due  examination  of 
this  question.  The  French  experience,  if  it  were  available, 
would  be  of  much  use  on  this  point,  as  they  performed  many 
capital  operations  in  their  trench  ambulances. 

Whatever  that  condition  is  which  is  conventionally  known 
as  'shock,'  it  seems  pretty  evident,  from  the  admission  of 
all,  that  it  is  not  established  for  some  little  time  after  the 
receipt  of  injury  —  an  interval  which  differs  in  duration 
mainly  in  accordance  with  the  severity  of  the  wound,  the 
agency  by  which  the  injury  has  been  caused,  and  probably 
the  constitution  of  the  sufferer.  The  evidence  of  naval 
surgeons,  as  summed  up  by  Mr.  Hutcheson,  in  reference  to 
the  absence  of  shock  immediately  after  the  receipt  of  a 
wound,  must  be  conclusive  to  all  unprejudiced  minds;  and 
instances  were  not  wanting  during  the  late  war  which 
appeared  to  support  the  same  view.  I  know  of  several 
well -authenticated  cases  which  occurred  during  the  siege, 
in  which  the  perfect  absence  of  all  constitutional  prostration 
after  an  accident  so  severe  as  the  carrying  off  of  a  limb,  and 
the  non-appearance  of  such  shock  for  some  considerable 
time  after,  went  to  prove  the  same  position.  If  this  precious 
moment  could  be  seized  at  all  times,  and  that  operation 
performed  under  chloroform,  which  assists  so  much  in  ward- 
ing off  the  "  ernbranlement"  we  fear,  how  much  more  suc- 
cessful would  our  results  prove,  than  under  any  other 
circumstances  they  ever  can  be  ! 

It  is  during  this  interval,  too,  that  we  obtain  the  full 


AMPUTATIONS.  323 

good  of  the  soldier's  moral  advantages  over  the  civilian. 
"Cut  off  the  limb  quickly,"  says  AViseman,  "while  the 
soldier  is  heated  and  in  mettle" — and  the  observation  is  as 
old  as  Pare,  that  while  excited  by  the  combat,  and  yet  within 
sound  of  the  cannon,  the  soldier  or  sailor  willingly  parts 
with  a  limb  which  a  few  hours  of  reflection  would  make  him 
desire  to  run  the  risk  of  preserving,  and  upon  which  he 
fixes  all  his  attention,  so  as  to  magnify  greatly  the  dangers 
of  the  subsequent  operation.  Moreover,  the  removal  of  the 
man,  before  operation,  to  any  distance  from  the  scene  of  his 
accident,  lessens  somewhat  his  chances  of  recovery;  as, 
besides  the  danger  that  the  irritation  and  pain  of  such 
transport,  however  carefully  it  may  be  conducted,  will  occa- 
sion— the  constitutional  depression  we  dread;  the  mere  loss 
of  blood  which,  although  going  on  in  very  small  quantities, 
is  yet  flowing  in  drops,  when  a  drop  may  extinguish  life,  are 
serious  objections  to  the  shortest  delay. 

But  even  although  that  constitutional  disturbance  which  is 
the  result  of  injury  is  present,  is  it  always  necessary  to  wait 
its  subsidence  before  operating?  If  it  be  very  decidedly 
marked,  and  the  patient  thus  much  prostrated,  such  delay 
may  certainly  be  called  for;  but  it  is  an  opinion  often  stated 
by  those  who  must  be  well  informed  on  the  subject,  that  such 
delay  is  not  always  advantageous,  but  manifestly  the  reverse. 
Larrey,  for  example,  gives  repeated  utterance  to  the  following 
sentiment:  "11  est  done  demontre  que  la  commotion,  loin 
d'etre  une  centre-indication  a  1'amputation  primitive,  doit  y 
determiner  le  chirurgeon ;"  and  again  :  "  Les  effets  de  la  com- 
motion loin  de  s'aggraver,  diminuent  et  disparaissent  insensi- 
blemerit  apres  1'operation  ;"*  and  in  this  opinion  he  is  by  no 

*  "  J'ai  vu  perir  un  asse/  grande  nombre  do  militaires  quoique 
OJM'-K'S  dans  les  vingt-quatre  lieures  parce  que  1' operation  avail  eu- 
core  6tc'  laite  trop  tard.  Kur  trois  que  j'ai  ampuh's  aux  deux  jambes 
a  la  bataillc  dc  Wnjrram  eelui  qui  avail  etc  opere  le  premier  et  pen 

d'instans  apics  U-  coup,  est  le  ser.l  que  ail  etc  sauve"." — L<it  >•:>/,  vi-1. 
iii.  p.  378. 


324  SURGERY   OE    THE    CRIMEAN    WAR. 

means  solitary,  as  may  be  seen  by  reference  to  the  writings 
of  many  naval  surgeons,  who  have  manifestly  the  best  oppor- 
tunities of  judging  in  the  matter.  The  upholding  influence 
of  chloroform  comes  strongly  into  play  in  such  cases,  and 
obviates,  in  a  great  measure,  the  dangers  which  have  been 
prognosticated  from  such  proceedings.  If  the  constitutional 
depression  be  the  result  of  an  injury  which  remains  as  a 
source  of  irritation,  then  the  removal  of  such  must  mani- 
festly be  a  great  point  gained;  and  I  know  it  is  the  opinion 
of  many  army  surgeons  of  large  experience,  that  the  presence 
of  shock  is  no  hinderance  to  operation,  (under  chloroform,)  if 
that  condition  be  not  very  decidedly  marked  at  the  moment 
of  interference. 

The  difficulty  which  chiefly  stands  in  the  way  of  instant  oper- 
ation is  the  recognition  of  the  cases  which  demand  it,  and 
the  certainty  that  no  fatal  internal  lesion  may  not  have  been 
at  the  same  time  sustained,  as  the  accident  to  the  limb  which 
necessitated  its  removal.  However,  it  would  certainly  tend, 
on  the  whole,  to  the  saving  of  life,  to  operate  as  soon  as 
possible,  not  only  in  all  those  cases  in  which  the  necessity  for 
it  was  evident,  but  also  in  all  doubtful  cases  ;  as,  although  a 
few  limbs  might  thus  be  sacrificed,  I  have  not  the  least  doubt 
but  that  many  lives  would  be  saved.* 

*  In  fact,  there  can  be  little  doubt  but  that  it  would  tend  greatly 
to  the  preservation  of  life  in  an  army  on  active  service,  if  it  were 
made  imperative  on  surgeons  to  operate  in  certain  contingencies,  in 
place  of  leaving  it,  as  at  present,  to  the  discretion  of  each  what  cases 
to  preserve  and  what  to  operate  on;  as  the  undoubted  tendency 
among  surgeons — notwithstanding  the  prejudice  which  so  long  ex- 
isted to  the  contrary — is  to  amputate  too  little  on  the  field  of  battle. 
1  know  full  well  such  a  regulation  could  not  be  made,  nor  would  it 
be  withstood  by  a  medical  stafl';  but  judged  of  merely  as  bearing  on 
icsults,  I  have  little  doubt  but  that  it  would  be  successful.  As  was 
said  when  speaking  of  compound  fractures  and  wounded  joints,  every 
succeeding  generation  of  surgeons  go  through,  to  a  great  extent,  the 
same  ordeal  in  gaining  their  experience.  They  suppose  their  ad- 
vanced attainments  encourage  an  attempt  which  their  predecessors 


AMPUTATIONS.  325 

The  Crimean  war  afforded  a  most  excellent  field  for  ob- 
serving the  relative  value  of  flap  and  circular  amputations  ; 
as,  although  in  our  army  the  former  was  commonly  employed, 
most  of  the  French  and  not  a  few  of  our  own  surgeons  ad- 
hered to  what  Sir  C.  Bell  termed  "the  perfection  of  the 
operation  of  amputation."  As  the  advantage,  in  general, 
of  removing  the  limb  as  far  as  possible  from  the  trunk  is 
fully  recognized,  it  seems  curious  that  the  circular  mode  of 
operating,  which  I  think  admits  of  this  more  than  the  oper- 
ation by  flaps,  should  not  be  more  followed.  In  the  lower 
part  of  the  thigh  this  is  particularly  observed.  Protrusion 
of  bone  is  the  great  bugbear  which  terrifies  most  operators; 
hence  they  make  unnecessarily  long  flaps,  and  remove  a  much 
larger  amount  of  the  bone  than  is  at  all  necessary.  This 
was  very  apparent  in  many  amputations  in  the  East.  Mr. 
Syme  has  laid  down  the  true  principle  which  should  regulate 
our  proceedings,  when  he  says :  "It  is  not  the  length  of  the 
flaps  which  prevents  the  risk  of  protrusion  of  the  bone,  but 
the  height  at  which  it  is  divided  above  the  angle  of  union 
of  the  flaps." 

In  soldiers,  as  in  many  (although  not  all)  cases  submitted 
to  primary  amputation  for  accident  at  home,  the  proportion 


feared,  and  thus  a  vast  number  of  lives  are  ever  being  sacrificed  to 
the  establishment  of  individual  experience.  Were  it  possible  that  a 
commission,  a  chief,  an  academy,  or  any  competent  body  having 
authority,  were  to  lay  down  instructions  at  the  beginning  of  a  cam- 
paign binding  on  the  surgeons  of  an  army,  with  reference  to  points  fully 
established  by  a  large  and  sufficient  induction,  as  well  as  those  which 
called  for  their  investigation,  I  have  little  doubt  but  that  a  large  pro- 
portion of  lives  would  be  saved  during  each  war,  and  a  mass  of  re- 
liable facts  added  to  our  knowledge.  The  fluctuating  state  of  our 
knowledge  upon  those  cases  which  demand  immediate  amputation 
might  be  thus  thrown  into  shape  and  made  available,  while  those 
operations  would  alone  be  made  imperative  the  justness  of  which  was 
beyond  doubt.  Such  an  arrangement  as  that  hinted  at,  in  place  of 
being  a  hinderance  to  the  advance  of  our  knowledge,  would,  in 
truth,  promote  it. 

28 


326  SURGERY    OF    THE    CRIMEAN    WAR. 

of  muscle  to  skin  and  subcutaneous  fat  is  different  from  what 
it  is  in  most  cases  operated  on  in  civil  hospitals,  and  thus 
modifies  our  appreciation  to  some  extent  of  the  two  modes 
of  operating.  In  soldiers  there  is  commonly  but  little  sub- 
cutaneous fat,  and  the  muscles  are  large  and  strong ;  hence 
it  becomes  very  difficult,  when  practicing  the  flap  operation, 
to  adapt  the  parts  to  one  another,  so  as  to  fulfill  the  latter 
part  of  the  old  maxim,  "muscle  must  cover  bone,  and  in- 
tegument muscle."  It  cannot  be  said  that  this  arose  in  the 
East  from  the  maladroit  performance  of  the  operation  by 
the  flap,  as  the  same  circumstance  may  be  seen  to  occur  at 
home  in  the  hands  of  our  ablest  hospital  surgeons.  The 
paring  and  stuffing-in  processes  which  are  not  uncommonly 
seen  in  hospitals,  to  correct  the  results  of  the  condition 
referred  to,  are  no  less  prejudicial  than  unsightly.  The  irri- 
tation is  thereby  increased,  and  proper  adhesion  of  the  parts 
prevented.  In  secondary  amputation  the  excess  of  skin  re- 
moves any  fear  of  similar  accidents.  Chloroform  has  refuted 
the  argument  in  favor  of  the  flap  operation,  founded  on  the 
greater  speed  of  its  performance  than  the  circular,  as  such 
great  speed  is  now  a  matter  of  no  moment.  But  however 
it  be  with  regard  to  the  question  in  general,  there  is  one  fact 
which  any  one  who  had  opportunities  of  watching  matters 
during  the  early  part  of  the  late  war  will  amply  verify,  viz., 
that  the  circular  stumps  stood  the  transit  to  the  rear  much 
better  than  those  formed  by  the  flap  method,  and  thus  it 
would  seem  that  the  former  mode  of  operating  is  more  ad- 
vantageous in  military  practice  than  the  latter.  The  long, 
heavy  flaps  were  so  knocked  about  during  the  land  and  sea 
passage  that  they  often  became  loose,  got  bruised,  and  ended 
by  sloughing;  while  the  firm,  compact  stumps  made  by  the 
circular  method  were  little  if  at  all  injured.  When  patients 
can  be  treated  in  camp  to  a  termination,  the  influence  of 
this  circumstance  is,  of  course,  null.  It  may  be  said  that 
the  length  of  the  flaps  was  a  mistake  committed  in  the  oper- 
ation, but,  unfortunately,  such  errors  must  always  be  looked 


AMPUTATIONS.  327 

for  in  like  circumstances,  where  there  is  a  large  body  of  oper- 
ators, most  of  them  without  previous  experience  in  operating, 
and  whose  chief  fear  always  is  to  have  "too  little  flap;"  for 
although  it  is  true  what  Hammick  says,  that  "it  requires 
more  practical  experience  to  know  when  to  take  off  a  limb 
than  how  to  do  it,"  yet  the  how  must  also  be  studied,  like 
everything  else. 

In  considering  the  statistics  of  amputation  performed 
during  the  Crimean  war,  the  figures  refer  solely  to  the 
period  between  the  1st  of  April,  1855,  and  the  end  of  the 
war,  and  consequently  exclude  all  the  unfavorable  part  of 
the  campaign,  as  well  as  the  greater  number  of  the  opera- 
tions which  were  absolutely  performed  during  the  war.  It 
was  found  impossible  to  attain  to  accuracy  with  regard  to 
the  earlier  period,  so  the  field  o,f  observation  was  restricted 
as  stated.  It  is  needless  to  point  out  how  different  must 
be  the  lessons  derivable  from  the  statistics  of  this  latter 
period  alone,  to  what  they  would  have  been  if  the  whole 
period  of  the  war  had  been  included.* 

During  the  limited  period  I  have  mentioned,  there  were 
732  amputations  in  all  parts  performed,  followed  by  death 
in  201  instances;  of  these,  654  operations  and  1G5  deaths 
were  primary,  and  78  operations  with  36  deaths,  secondary; 
giving  a  percentage  of  27 '4  deaths  overhead — 25-22  for  the 
primary,  and  46 '1  for  the  secondary  operations.  If  we  in- 
clude only  the  greater  operations,  viz.,  amputations  of  the 
shoulder,  arm,  and  forearm,  of  the  hip,  thigh,  knee,  and  leg, 
then  we  have  a  total  of  500  cases  and  199  deaths,  or  39 '8 
per  cent.;  of  which  total  440  cases  and  163  deaths,  or  37 

*  In  my  original  papers  the  figures  were  intended  to  represent  the 
period  of  the  whole  war.  I  have  reason  to  think  that,  although 
upon  a  more  careful  investigation  of  the  returns  than  could  be  made 
in  the  Crimea,  these  numbers  have  since  proved  not  strictly  accurate, 
thev  yet  represent  prettv  much  the,  results  which  followed  many  of 
the  operations  as  viewed  in  the  more  lengthened  and  less  favorable 
aspect,  of  the  w;ir. 


328  SURGERY   OF   THE    CRIMEAN    WAR. 

percent.,  were  primary,  and  60  cases  and  36  deaths,  or  60 
per  cent.,  were  secondary.* 

The  increase  of  the  mortality  as  we  approach  the  trunk 
may  be  shown  thus,  taking  the  primary  amputations  alone 
as  giving  the  most  unbroken  series  : — 

SUPERIOR    EXTREMITY. 
r.irt  Ratio  mortality 

per  cent. 

Fingers 0-5 

Forearm  and  wrist 1-8 

Arm 22  9 

Shoulder  joint 27-2 

INFERIOR    EXTBEM1TY. 

par£  Ratio  mortality 

per  cent. 

Tarsus 14-2 

Ankle-joint 22-2 

Leg 30-3 

Knee-joint 50-0 

Thigh,  lower  third 500 

middle    "    55-3 

"       upper     "   80-8 

Hip-joint 100-0  v 

The  lower  extremity  was  removed  at  the  hip-joint  seven 
times  during  the  period  included  in  the  returns,  and  at  least 
three  times  more  previously,  giving  ten  cases,  all  primary 
operations,  and  all  ending  rapidly  in  death.  One  of  these 
cases  was  operated  on  by  my  lamented  friend  Dr.  Richard 
M'Kenzie,  after  the  Alma.  The  French  had  thirteen  cases, 
primary  and  secondary,  after  the  Alma  and  Inkerman,  and 
all  died.  One  of  these,  a  Russian,  was  operated  on  by  M. 
Legouest  on  the  3d  of  October,  1855,  at  Constantinople. 
The  upper  part  of  femur  was  completely  smashed  by  a  coni- 
cal ball.  The  flaps  had  adhered  to  a  point  by  the  middle  of 
December,  at  which  date  I  saw  the  patient  walking  about 
the  ward  on  crutches,  and  looked  upon  by  all  as  being  be- 

*  See  Appendix  G. 


AMPUTATIONS.  329 

yoncl  danger.  The  very  night  on  which  the  order  arrived 
for  sending  him  to  France — where  he  was  to  be  admitted, 
by  special  permission,  into  the  Yal  de  Grace — he  fell  when 
walking  in  the  corridor,  and  hurt  his  stump  so  that  it  bled 
profusely.  Inflammation  was  set  up,  suppuration,  renewed 
hemorrhage,  and  diarrhoea  followed,  and  he  died  on  the  9th 
of  February,  four  months  after  operation.  M.  Mounier,  in 
the  same  hospital,  had  three  cases,  one  of  which  I  watched 
with  interest.  Two  of  these  died  of  hemorrhage,  one  on 
the  fifteenth,  and  the  other  on  the  twentieth  day.  The  third 
died  of  cholera.  One  of  these  men  was  a  Russian. 

The  mortality  which  has  thus  followed  exarticulation  at 
the  hip,  during  the  Eastern  campaign,  has  been  very  deplor- 
able ;  yet,  in  the  cases  in  which  it  was  performed,  no  other 
alternative  remained,  except  to  abandon  them  to  inevitable 
death,  which  many  might  be  disposed  to  think  the  more 
humane  proceeding,  as  they  often  linger  for  a  long  period 
before  death.  M.  Legouest's  case  was  unquestionably  suc- 
cessful ;  and,  although  we  can  hardly  hope  with  Lurrey  that 
this  operation  will  ever  be  performed  as  readily  as  his 
favorite  one  at  the  shoulder-joint,  still  the  results  of  opera- 
tion at  the  hip  for  accident  have  not  been  so  utterly  hope- 
less as  to  lead  us  to  abandon  it.  M.  Legouest  has  given, 
in  a  most  interesting  paper  on  the  case  mentioned  above,  a 
table  containing  most  of  the  recorded  cases  of  amputation 
at  the  hip  for  gunshot  wounds.  Of  primary  operations  he 
has  collected  30  cases,  all  ending  fatally;  of  intermediate  or 
early  secondary  operations  ]}e  finds  mention  of  11  cases, 
with  3  recoveries;  and  of  operations  performed  at  a  period 
so  late  as  that  "  the  injury  had  lost  all  its  traumatic  char- 
acter," 3  cases,  with  one  recovery.  Thus,  if  we  sum  up  the 
whole,  we  have  4  recoveries  in  44  cases,  or  a  mortality  of 
90'9  per  cent.  Some  of  the  primary  cases  died  on  the 
table ;  all  of  them  before  ten  days  except  2,  which  perished 
within  a  month.  The  proportion  of  recoveries  among  those 
operated  on  after  the  primary  period,  but  before  a  long 

28* 


330  SURGERY   OF   THE   CRIMEAN    WAR. 

elapse  of  time,  i.e.  at  some  period  during  the  existence  of 
"the  traumatic  phenomena,"  was  the  largest,  and  hence  that 
would  seem  the  best  time  to  undertake  the  operation. 

During  the  Sleswick-Holstein  war,  amputation  at  the  hip 
was  performed  T  times — 5  were  operated  on  by  Langenbeck  ; 
only  1  of  these  cases  recovered.  I  find  no  mention  whether 
these  cases  were  primary  or  secondary.  In  the  Indian 
campaigns  I  find  mention  of  only  1  case  of  amputation  at 
the  hip  for  a  gunshot  wound.  It  was  a  primary  operation, 
and  took  place  in  the  Punjab.  Thus,  if  we  reckon  the 
whole  number  of  cases  operated  on  for  gunshot  wounds, 
those  recorded  by  Legouest,  our  own  Crimean  cases,  and 
the  Holstein  and  Indian  ones,  we  find  a  total  of  62  cases, 
and  5  recoveries,  or  a  mortality  of  91 '9  per  cent. 

Mr.  Sands  Cox,  recording  the  experience  of  civil  hospi- 
tals as  well  as  those  of  military  practice,  up  to  1846,  gives 
in  all  84  cases,  most  of  them  for  injury,  with  26  recoveries ; 
14  of  these  successful  cases  being  after  accident,  and  of  the 
unsuccessful,  20  were  for  injury;  and  in  the  Medical  Times 
and  Gazette  for  April,  185T,  there  is  a  further  record  of  8 
cases,  of  which  2  were  for  accidents,  (1  primary  and  I 
secondary,)  with  3  recoveries,  all  after  operations  for  dis- 
ease.* Cox  recognizes  the  difficulty  of  restraining  the 
hemorrhage  during  the  operation,  and  the  shoc£  given  to 
the  nervous  system,  as  the  great  sources  of  danger.  The 
hemorrhage,  at  a  considerable  period  after  operation,  would 
appear  even  a  more  common  cause  of  the  fatal  event  than 
the  difficulty  of  commanding  it^at  the  time. 


•"  In  the  New  York  Journal  of  Medicine  for  October,  1852,  there  is 
a  paper  by  Dr.  Smith,  on  the  subject  of  amputation  at  the  hip,  in 
•which  he  gives  a  summai-y  of  98  cases,  showing  a  ratio  of  mortality 
of  1  in  2|.  In  62  of  these  cases,  of  which  he  learned  the  particulars, 
the  operation  was  performed  for  injury  in  30  cases,  and  the  per- 
centage of  deaths  was  60.  He  remarks  one  curious  circumstance, 
viz.,  that  the  ratio  of  mortality  has  most  suddenly  and  markedly 
diminished  since  1840,  and  no  reason  can  be  given  for  this,  unless  it 
be  increased  care,  better  operative  ability,  and  the  use  nf  anest'teli  s. 


AMPUTATIONS.  331 

It  will,  of  course,  only  be  in  the  event  of  such  destruction 
to  the  bone  or  soft  parts,  or  such  other  injury  to  the  nutri- 
tion of  the  extremity,  as  puts  resection  out  of  our  power, 
that  amputation  will  be  performed.  If  the  fracture  of  the 
neck  of  the  bone  were  slight,  as  when  occasioned  by  a  small 
ball,  or  one  striking  with  little  propulsive  force,  such  as  that 
projected  by  the  match-lock,  then  the  case,  I  conceive,  must 
be  viewed  more  as  a  compound  fracture  of  the  upper  part  of 
the  thigh,  and  should  be  treated  accordingly.  M.  Legouest 
lias  recorded  6  cases  in  which  the  limb  was  not  removed  or 
resected,  and  3  of  these  recovered.  One  of  these  cases  of 
recovery  having  occurred  in  1812,  must  have  been  wounded 
by  a  round  ball;  the  second  was  injured  in  a  duel,  and  hence 
probably  by  a  small  light  ball ;  while  the  third  was  observed 
in  Africa,  where  neither  the  size  nor  the  form  of  the  balls 
used  by  the  natives  is  to  be  compared  to  the  conical  bullet. 
All  three  were  struck  on  the  trochanter.  The  3  fatal  cases 
with  us  which  were  not  interfered  with,  took  place  after  the 
Alma  and  Inkerman,  and  hence  were  probably  wounded  by 
conical  balls. 

All  are  agreed  that,  when  practical,  the  separation  of  the 
limb  should  be  accomplished  at  or  through  the  trochanter, 
rather  than  at  the  joint,  on  account  of  the  diminished  risk; 
and  this  can  be  more  often  executed  than  would  at  first 
appear,  as  it  not  uncommonly  happens  that  the  fracture  does 
not  extend  to  the  head  of  the  bone,  as  it  seemed  at  first 
sight  to  do;  hence  it  might  be  judicious,  in  all  doubtful 
cases,  to  make  the  incisions  so  low  as  to  suit  amputation  at 
the  trochanter.  The  steps  necessary  for  exarticulation  can 
easily  be  taken,  if  called  for  afterward,  when  the  bone  is  ex- 
amined. Such  a  proceeding  would  certainly  not  be  very 
"  brilliant,"  but  it  might  save  a  life. 

After  the  1st  April,  1855,  amputation  in  the  upper  third 
of  the  thigh  was  performed  39  times,  with  a  fatal  result  in 
34  cases.  Of  the  total  number  only  one  was  a  secondary 
<>;>"ration,  and  it  ended  fatally.  The  ratio  mortality  per 


332  SURGERY   OF   THE   CRIMEAN    WAR. 

cent,  was  thus  86'8  for  primary,  and  100  for  secondary.  I 
have  never  myself  seen  any  case  recover  in  which  the  limb 
was  amputated  beyond  doubt  in  the  upper  third,  and  I  never 
met  any  one  who  had  except  in  one  instance,  and  that  man 
was  seen  in  England.  I  saw  several  upper-third  amputa- 
tions, so  called,  which  were  riot  really  so.  It  is  very  easy 
to  be  deceived  on  this  point.  The  French  and  Russians 
found  these  operations  so  hopeless  that  they  almost  aban- 
doned them  ;  and  in  fact,  as  was  before  remarked,  the  at- 
tempt to  save  such  limbs,  hopeless  as  it  was,  seemed  more 
promising  than  amputation  in  the  field. 

Amputation  in  the  middle  third  was  performed  during 
the  period  after  the  1st  April,  1855,  65  times,  of  which  num- 
ber 38  died ;  56  of  these  cases  and  31  deaths  were  primary 
operations,  giving  a  ratio  mortality  per  cent,  of  55 -3  ;  9 
cases  were  operated  on  at  a  late  period,  and  7  died,  or  7  7 '7 
per  cent.  Amputation  in  the  lower  third  was  performed 
during  the  same  period  60  times,  46  being  primary,  and  14 
secondary  operations  :  of  the  primary,  23,  or  50  per  cent, 
died;  and  of  the  secondary,  10,  or  71 '4  per  cent.  A  very 
great  many  of  the  operations  classed  as  "  lower  third"  ought 
to  have  been  entered  as  "  middle  third,"  as  it  very  frequently 
happened  that,  from  the  operator  adhering  too  closely  to  the 
maxim  of  Petit,  to  "cut  as  little  of  the  muscle  and  as  much 
of  the  bone  as  possible,"  an  operation  which  was  ostensibly 
in  the  lower  was  in  reality  in  the  middle  third.  This  is  a 
matter  of  which  I  have  seen  many  illustrations  ;  conse- 
quently I  believe  that  at  least  one-third  of  the  operations 
and  the  deaths  classed  as  lower  third  should  be  transferred 
to  the  middle  third  column,  and  thus  the  relative  frequency 
and  fatality  of  the  two  operations  would  be  better  expressed. 

Taking  amputations  in  all  parts  of  the  thigh,  then,  we 
find  the  number  of  operations  after  the  1st  of  April,  1856, 
was  164,  of  which  number  140  were  primary,  and  24  secon- 
dary operations.  The  total  mortality  was  105,  or  64  per 
cent.  Of  the  total  deaths,  the  primary  amputations  yielded 


AMPUTATIONS.  333 

87,  or  C2-2  per  cent.,  and  the  secondary  18,  or  75  per  cent. 
It  must  always  be  borne  in  mind  that  these  results  only  refer 
to  the  period  of  the  war  when,  as  was  before  stated,  secondary 
operations  were  becoming  very  rare,  and  the  state  of  mat- 
ters in  camp  so  improved  that  the  total  mortality  after  am- 
putations was  by  no  means  what  it  had  been  at  an  earlier 
period ;  so  that  to  say  that  the  average  mortality  after  am- 
putation of  the  thigh,  in  the  Crimea,  was  64  per  cent.,  does 
not  by  any  means  express  the  whole  truth.  However,  if  we 
take  the  later  period  only  into  consideration,  then  our  results 
may  be  thus  contrasted  with  those  obtained  in  other  fields 
of  observation  : — 

TABLE  SHOWING  THE  FERCEXTAOK  OF  DEATHS  AFTER  AMITTATIOX 
(PRIMARY  AND  SECONDARY)  OF  TUB  TIIHSH  FOR  GUNSHOT  WOUNDS 
AND  ACCIDENTS. 

Mortality 
per  cent. 

Crimea,  British  army  from  April  1st  to  end  of  war.. <>H> 

Constantinople,  French  Dolma  Batch!  Hospital,  Mouriicr...  8lM> 

Naval  Brigade,  Crimea (>•">•<» 

Indian  campaigns 48-7 

Waterloo 70-2* 

Spain,  Alcock OiM) 

Sleswick-Holstein,  Esmarch 60-15 

Danish  army,  1848-50,  Djorup 56-7 

Sedillot,  "  Campagne  Constantine,"  1837 8~-"> 

Africa,  Baudens 51-4 

Polish  campaign,  Malgaigne 1000 

Mexican  war lOO'O 

Hotel-Dieu,  1880 81-8 

Cases  communicated  to  the  Academy,  1848 77-2 

INJURY. 

Phillips 71-8 

Parisian  Hospitals,  Malgaigne 73  9 

*  I  have  in  this  computation  taken  for  granted  that  one-third  of 
the  Cfises  "remaining"  at  the  time  the  return  given  by  Mr.  Guthrie 
was  completed  ended  unfavorably,  which  appears  a  very  moderate 
allowance,  when  we  find  such  a  proportion  as  51  out  of  (.H  cases  of 
secondary  amputation  so  entered,  and  3")  of  the  primary. 


334  SURGERY   OF    THE    CRIMEAN    WAR. 

Glasgow,  previous  to  1848,  Lawrie 75:0 

"          M'Ghie 78  -C* 

"          Steele 72-0 

St.  Thomas's  Hospital,  South 85-7 

Hussey 62-5 

James,  all  primary 61-5 

University  College,  Erichsen 60-8 

The  usual  discrepancy  which  marks  statistical  tables  is 
observable  in  the  above  enumeration.  That  between  the 
results  obtained  in  our  army  and  those  quoted  from  the 
French,  and  which  were  kindly  furnished  to  me  by  M.  Mou- 
nier,  is  easily  understood  when  it  is  stated  that  of  the  total 
number  of  46  amputations  of  the  thigh  which  presented 
themselves  in  the  hospital  presided  over  by  that  distin- 
guished surgeon,  25  were  secondary  operations,  all  of  whom 
perished,  while  in  our  returns,  and  those  of  the  Naval  Bri- 
gade, there  were  very  few  consecutive  amputations.  Out  of 
21  primary  amputations  reported  by  M.  Mounier,  8  recov- 
ered. The  low  mortality  among  the  Indian  cases  is  some- 
what difficult  to  account  for.  In  calculating  them,  I  did  not 
include  any  case  except  those  the  result  of  which  I  could  find 
well  authenticated.  To  distinguish  between  primary  and 
secondary  operations,  in  many  of  the  cases  recorded  by  the 
various  authors  referred  to  in  the  above  table,  was  found 
impossible  ;  but  so  far  as  this  can  be  accomplished  appears 
in  the  following  table  : — 

*  These  numbers  are  derived  from  a  further  investigation  of  the 
Royal  Infirmary  records  by  Dr.  M'Ghie  and  myself,  and  include  the 
cases  operated  on  for  twelve  years  previous  to  1853. 


AMPUTATIONS. 


335 


TABLE  SHOWING  TIIK  .MORTALITY  AFTER   PHI.MVRY  AND  SECONDARY 
[DISTINGUISHED)  AMPUTATIONS  OF  TIIK  THIGH  FUR  GUNSHOT  WOUNDS. 


Mortality  per  cent. 

Primary. 

S-nmdary. 

Crimea   after  April  1    1805 

62-0 

r.H.i 

75-0 
100-0 

loo-o 
60-0 

tilt  0 

60-0 

Ni  o 

81-2 

Constantinople    Mounter.         

Leerouest            .                    

N;ival  Brigade1*            .       

66-0 

:;s  o 
C.4-7 
13  3 

57-0 

Cases  commuiiitMU'd  to  (he  Academy,  1848, 
in  which  the  distinction  is  drawn  

TABLE  SHOWING  THE  MORTALITY  AFTER  PRIMARY  AND  SECONDARY 
(DISTINGUISHED)  AMPUTATIONS  OF  THE  THIGH  FOU  INJURY. 


Mortality  iM?r  cent. 

Primary. 

Sfci  'inlary. 

75-0 
91-6 
66-6 
61-2 

100-0 

67-0 

83-0 
61  '6 

60-0 

<;r,  of 

DIM; 
500 

•;-  r, 

Glasgow   Lawrie 

"         Steele 

"         M'Ghie        ....          

St   Thomas's  Hospital    South  

University  College    ErichSGD  

James 

*  These  numbers,  as  well  as  those  given  in  the  previous  table,  do 
not  refer  merely  to  the  Naval  Brigade  as  serving  in  the  Crimea,  but 
to  the  operations  performed  at  the  hospital  on  the  Bosphorus. 

f  Dr.  Simpson  has  completely  confused  Dr.  Lawrie's  statistics, 
having  mixed  up  his  primary  and  secondary  amputations  and  those 
for  disease.  Thus,  he  gives  35  cases  of  primary  amputation  and  27 
deaths,  as  occurring  in  Dr.  Lawrie's  paper,  in  which  mention  is 
made  of  only  12  cases  and  11  deaths,  out  of  85  cases  and  U7  deaths 
of  primary  and  secondary  cases  combined;  and  under  the  head  of 
secondary  operations  he  has  given  those  for  disease. 


336  SURGERY    OF   THE    CRIMEAN    WAR. 

If  a  calculation  is  made  of  the  mortality  succeeding  am- 
putation of  the  thigh  from  gunshot  wounds  alone,  and  the 
whole  number  of  cases  referred  to  in  the  above  table  included, 
then  the  average  mortality  per  cent,  of  primary  operations 
would  appear  to  be  56'5,  and  of  secondary  79-0;  while,  if 
the  operations  performed  in  civil  hospitals  for  injury  are  alone 
calculated,  then  the  average  mortality  of  primary  operations 
would  appear  as  69'6  per  cent,  and  secondary  75'4 — a  re- 
sult somewhat  different  from  what  is  usually  obtained. 

Amputation  through  the  knee-joint  has  been  performed 
in  our  army  6  times  primarily,  3  of  which  were  fatal,  and 
once  secondarily,  with  a  fatal  result.*  This  very  old  oper- 
ation has  lately  been  creating  some  interest  in  the  profession, 
and  was  often  performed  by  the  French  surgeons  in  the 
Crimea.  The  opinion  they  were  led  to  form  of  it  may  be 
supposed  to  be  expressed  by  Bandens,  when  he  says,  ( Une 
Mission  Medicale  en  Crimee:)  "It  is  a  truth  which  the 
numerous  facts  observed  in  the  Crimea  permit  us  to  affirm, 
that,  whenever  it  is  impossible  to  amputate  the  leg,  the  dis- 
articulation  of  the  knee  should  be  preferred  to  amputation 
of  the  thigh.  The  former  has  more  often  succeeded  than 
the  latter."  There  are  not,  however,  very  many  cases  oc- 
curring in  the  field  which  are  adapted  for  this  operation,  as 
it  should  be  performed  only  when  the  injury  is  limited  to  the 
leg-bones  and  the  femur  remains  intact ;  and  when  this  takes 
place,  it  often  happens  that  the  soft  parts  are  so  much  im- 
plicated as  to  deprive  us  of  flaps.  However,  if  the  poste- 
rior flap  is  destroyed,  we  can  take  a  long  flap  from  the  front, 
and  vice  versa.  To  4  of  the  cases  operated  on  in  camp, 
with  the  details  of  which  I  am  acquainted,  the  operation 

*  Of  the  37  cases  of  this  operation  mentioned  by  Chelius  as  hav- 
ing been  collected  by  Jaeger,  22  were  favorable.  Dr.  Markoe,  New 
York  Journal  of  Medicine,  January,  1856,  gives  the  results  of  18 
operations  performed  since  1850  in  America  ;  5  of  these  were  fatal. 
If  to  these  we  add  6  cases  which  have  been  more  recently  published, 
with  1  death,  we  have  a  total  of  61  cases  and  21  deaths,  or  34-4  per 
cent,  mortality. 


AMPUTATIONS.  33T 

was  not  applicable,  as  the  femur  was  more  or  less  injured  so 
as  to  call  for  the  removal  of  part  of  it ;  hence  the  opera- 
tion, although  termed  amputation  through  the  knee,  was  in 
reality  low  amputation  of  the  thigh,  such  as  that  now  em- 
ployed in  white  swelling  of  the  articulation. 

As  to  the  mode  of  operation,  the  French  mostly  adopted 
Baudens's  method  ;  but  in  5  cases  operated  on  in  the  general 
hospital,  that  proceeding  was  departed  from  in  so  far  as  that 
the  posterior  flap  was  made  from  within  outward  in  place 
of  the  reverse,  as  directed  by  that  well-known  surgeon.  The 
anterior  flap,  too,  was  not  made  so  long.  Whatever  method 
of  operating  be  adopted,  the  great  point  which  demands 
attention  is  to  have  the  flap  sufficiently  broad  to  cover  the 
expanded  end  of  the  femur,  which  there  requires  a  large  and 
broad  covering.  Of  the  5  cases  operated  on  in  the  general 
hospital,  one  died  of  phagedenic  sloughing  on  the  forty- 
third  day ;  another,  a  soldier  of  the  62d,  died  of  enteritis 
on  the  sixty-seventh  day,  the  stump  being  healed  to  a  point; 
a  third  sank  from  exhaustion  on  the  ninth  day  after  opera- 
tion ;  a  fourth  never  fairly  recovered  from  the  shock  ;  while 
the  fifth  and  last  case  recovered,  under  the  charge  of  Dr. 
George  Scott,  who  operated  on  him.  This  patient,  a  soldier 
in  the  Buffs,  was  struck  on  the  right  knee-joint  by  a  ball,  on 
the  8th  of  September.  He  thought  himself  very  slightly 
injured,  as  the  only  thing  he  observed  wrong  with  the  joint 
was  his  inability  to  flex  it,  on  account  of  "something  catch- 
ing in  it."  A  small  opening  was  found  in  the  middle  of  the 
popliteal  space,  slightly  external  to  the  middle  line,  from 
which  a  good  deal  of  blood  flowed.  This  opening  led  into 
the  cavity  of  the  articulation,  and  spicuhc  of  bone  were  felt 
within.  A  part  of  the  end  of  the  femur  was  removed,  but 
the  patella  left.  A  round  ball  had  pierced  the  external 
condyle  and  lodged.  The  posterior  flap  eventually  sloughed 
and  exposed  the  end  of  the  femur ;  but  the  bone  became 
subsequently  covered  over  with  granulations,  and  though 
the  patient's  progress  toward  recovery  was  much  impeded 

20 


338         SURGERY  OF  THE  CRIMEAN  WAR. 

by  the  formation  of  an  abscess  among  the  muscles  of  the 
thigh,  which  required  extensive  incisions,  he  went  to  England 
in  perfect  health  in  January.  His  stump  was  strong  and 
firm,  and  he  had  much  power  over  its  movements.  The 
patella  could  be  felt  on  the  upper  surface,  to  which  position 
it  had  been  gradually  retracted.  In  several  of  the  cases 
which  I  have  seen  in  the  French  hospitals,  where  sloughing 
of  the  flaps  had  taken  place  as  in  this  case,  and  exposed  the 
extremity  of  the  femur,  the  cartilages  were  alone  thrown  off, 
but  not  a  scale  of  bone. 

So  far  as  I  can  judge,  the  practical  advantages  of  this 
operation  are  equal  in  value  to  those  theoretical  ones  which 
its  advocates  claim  for  it,  and  they  would  seem  to  recommend 
its  more  general  adoption  in  any  future  campaign.  First 
of  all,  the  shock  to  the  system  is  less,  and  we  obtain  a  larger 
and  firmer  stump  than  when  the  femur  is  sawn  through  ;  the 
end  of  the  bone  on  which  the  patient  has  to  bear  his  weight 
is  likewise  more  expanded  and  more  rounded,  and  hence 
calculated  to  inspire  greater  confidence  in  the  patient  in  the 
use  of  it,  and  less  liable  to  cause  ulceration  by  its  pressure  on 
its  coverings.*  A  false  leg  can  be  more  easily  attached  to 
such  a  stump,  and  more  power  is  retained  in  progession  from 
the  muscles  which  remain  undivided,  than  when  the  limb  is 
amputated  in  the  continuity.  Few  now  participate  in  Lis- 
ton's  opinion  of  a  long  thigh  stump,  but,  on  the  contrary, 
most  surgeons  try  to  keep  their  section  as  far  as  possible 
from  the  trunk.  The  non-interference  with  .the  medullary 
canal  obviates  many  of  the  dangers  of  amputation,  according 

*  The  absorption  of  the  condyles  of  the  femur  which  may  go  on 
after  this  operation  is  illustrated  by  a  case  mentioned  by  M.  Legouest, 
(Amputation  partielles  du  pied,)  in  which  a  soldier  had  undergone 
amputation  at  the  knee  in  1800,  in  Italy,  and  "  the  enormous  tuber- 
osities  had  so  diminished  in  volume  that  no  trace  of  them  could  be 
recognized,  but  the  member  presented  a  cone  terminated  by  a  point." 
So  completely  had  the  part  changed,  that  it  was  only  after  very  care- 
ful examination  they  believed  the  man's  story,  that  he  had  been  am- 
putated at  the  joint. 


AMPUTATIONS.  339 

to  Cruveilhier ;  while  the  extremity  of  the  femur,  which  is 
largely  supplied  with  blood-vessels,  being  retained,  there  is 
less  fear  of  exfoliation  than  when  the  dense  tissue  of  the  bone 
has  been  opened  by  the  saw.  The  position  of  the  divided 
artery  in  the  center  of  the  flaps,  and  the  few  ligatures  which 
are  required,  are  further  arguments  in  favor  of  this  opera- 
tion. There  is  little  fear  but  that  the  flaps  will  adhere  over 
the  cartilaginous  extremity  of  the  bone — in  fact,  the  carti- 
lages soon  disappear  during  the  healing  process.  There  is 
some  appearance  of  force  in  the  objection  which  some  have 
advanced  to  the  operation,  that  from  the  length  of  the  stump 
no  proper  space  is  left  for  the  play  of  an  artificial  joint ;  but 
if  it  be  evident,  as  civil  statistics  at  least  prove,  that  the 
fatality  attendant  on  this  operation  is  less  than  that  which 
follows  amputation  of  the  thigh,  then  any  such  objection 
loses  all  its  weight. 

If,  then,  cases  were  selected  for  the  operation  in  which 
the  femur  remaining  intact,  and  the  leg-bones  being  de- 
stroyed, a  sufficiency  of  flap  could  be  got  from  the  calf,  or 
the  front  of  the  leg,  and  if  the  amputation  was  performed 
early,  I  firmly  believe,  with  Malgaigue,  that  it  is  "  Encore 
une  de  ces  operations  trop  Irgrrement  condamnees,  et  qui 
lorsqu'on  a  le  choix  mcrite  toute  preference  sur  Pamputation 
de  la  cuisse  dans  la  continuitc." 

The  leg  was  amputated,  after  April  1,  1855,  101  times, 
with  death  following  in  36  cases,  giving  a  mortality  of  35 '6 
per  cent. ;  89  cases,  and  28  deaths,  were  primary  operations, 
and  12  cases,  with  8  deaths,  secondary — thus  affording  a 
ratio  of  mortality  per  cent,  of  31 '4  for  the  primary,  and  66*6 
for  the  secondary. 

The  rule  generally  followed  in  our  army  has,  I  think, 
been  to  preserve  as  much  as  possible  of  the  limb,  but,  except 
in  those  cases  in  which  the  operation  was  performed  just 
above  the  ankle-joint,  the  French  appeared  usually  to  ampu- 
tate at  the  place  of  election.  I  saw  no  instance  in  which 
Larrey's  operation  through  the  head  of  the  tibia  was  had  re- 


340  SURGERY   OF   THE    CRIMEAN    WAR. 

course  to,  but  I  am  informed  that  it  was  several  times  suc- 
cessfully performed  in  the  French  ambulances. 

The  greatly  improved  mechanical  contrivances  of  late  years 
have  much  changed  the  bearing  of  the  question  with  regard 
to  long  leg  stumps,  The  facility  and  moderate  cost  with 
which  artificial  limbs  can  now  be  fitted  to  any  part  of  the 
limb,  from  the  knee  to  the  foot,  has  obviated  many  of  the 
reasons  which  formerly  induced  surgeons  to  prefer  the  high 
operation.  Larrey's,  through  the  head  of  the  tibia,  is  a 
most  valuable  one  when  the  destruction  has  extended  high 
up  the  leg,  as  it  enables  us  to  retain  the  use  of  the  knee- 
joint,  as  well  as  diminish  the  risk  to  life.  That  at  "  the  place 
of  election  "  will,  of  course,  continue  to  be  employed  in  cases 
of  injury  above  the  middle  of  the  leg;  but  when  the  nature 
of  the  accident  permits  of  it,  the  part  of  the  leg  which  ap- 
pears to  combine  most  of  the  advantages  sought  in  leg 
stumps  by  both  the  surgeon  and  the  mechanician,  is  un- 
doubtedly that  in  the  center  of  the  middle  third.  The 
length  of  the  lever  thus  obtained,  the  diminished  bulk  of  the 
part,  and  consequently  of  the  truncated  section,  the  means 
of  covering  the  bones,  and  the  room  it  affords  for  attaching 
a  limb,  are  all  in  favor  of  this  locality.  Many  most  ad- 
mirable stumps  were  made  in  this  part  of  the  limb  during 
the  war.  In  operations  for  accident,  as  in  gunshot  wounds, 
we  can,  of  course,  operate  lower  in  the  leg  than  we  can 
when  the  operation  is  undertaken  for  disease,  from  the  ab- 
sence of  the  thickened  state  of  the  bone,  and  the  changed 
and  bound-down  tissues  which  are  so  common  in  cases 
operated  on  in  civil  hospitals. 

As  to  the  operation  just  above  the  ankle,  which  has  of 
late  years  caused  so  much  discussion  on  the  continent,  we 
had,  so  far  as  I  know,  no  experience  in  our  army ;  but  the 
French  had  a  good  number,  which,  so  far  as  the  condition 
of  the  stumps  went,  were  not  by  any  means  promising.  This 
operation,  although  revived  by  the  improved  method  of 
procedure  introduced  into  practice  by  M.  Lenoir,  is  yet  of 


AMPUTATIONS.  341 

sufficiently  old  date.  It  is  mentioned  by  Dionis  in  his 
"Cours  d'  Operations,"  and  was  practiced  by  Bromfield  in 
1740,  and  afterward  by  White,  Alanson,  and  Bell,  in  Eng- 
land. In  France,  Blandin  often  performed  it  in  recent 
times,  but  was  induced  to  abandon  it,  like  many  others, 
from  the  bad  results  his  method  of  operation  yielded.  By 
M.  Lenoir's  modification,*  and  M.  Martin's  artificial  limb, 
the  operation  promises  again  to  come  into  favor.  This 
operation  appears  to  me  to  have  a  special  bearing  on 
military  practice.  Its  value  will  be  best  judged  of  by  con- 
sidering— 1st,  its  safety;  and,  2d,  the  usefulness  of  the  result- 
ing stump.  As  to  the  first  point  there  can  be  no  question 
as  to  its  advantage  over  any  other  amputation  in  the  leg. 
The  greatly  diminished  bulk  of  the  soft  and  hard  parts  at  the 
place  of  section,  the  smaller  amount  of  shock  such  severance 
will  occasion,  and  the  more  rapid  closing  of  the  wound,  are 
all  incontestable.  Its  fatality  in  the  cases  operated  on  in 
France  has  been  only  as  one-sixth  or  one-seventh,  while  the 
mortality  of  amputation  at  the  place  of  election  is  more  than 
one-half,  (55  in  100  according  to  Malgaigne.)  In  some 
hospitals,  as  in  the  Beaujon,  the  mortality  has  been  even 
less  in  the  sus-malleolaire  operation  than  that  mentioned 
above:  thus  M.  Huguier  only  lost  1  out  of  14  cases.  So, 
then,  as  far  as  the  mortality  goes,  there  can  be  no  division  of 
opinion,  as  there  is  about  the  second  point,  viz.,  the  state  of 
the  stump  afterward.  The  difficulty  of  retaining  enough 
of  covering  for  the  bones,  the  fear  of  such  retraction  as  will 
occasion  a  conicity  of  the  stump,  the  tenderness  of  the 
cicatrix  and  its  inability  to  stand  pressure,  the  chance  of 
fusiform  collections  of  pus  forming  among  the  tendons,  of 
caries  or  necrosis  of  the  bones  following, —  all  these  are 
among  the  objections  which  have  been  advanced  to  the 
operation.  If  we,  however,  carefully  examine  these  by  the 


*  .Sec  Arcli.  (Jon.  <le  Med.,  July,  18-10,  and  Me.noiro  by  Arnal  ami 
Martin,  Paris,   IS4U. 

20* 


342  SURGERY   OF    THE   CRIMEAN    WAR. 

light  of  the  large  number  of  observations  which  can  now  be 
brought  to  bear  on  the  subject,  we  find  that  the  only  objec- 
tions which  are  of  any  weight  are  the  scanty  covering  of 
soft  parts,  the  tenderness  of  the  cicatrix,  and  the  risk  of 
necrosis.  Purulent  collections  can  be  easily  avoided  by 
careful  dressing ;  and  the  presence  of  the  other  evils,  and,  in 
fact,  the  want  of  flap  also,  must  be  referred  to  the  manner  in 
which  the  operation  has  been  performed.  I  have  examined 
a  considerable  number  of  those  amputated  in  Paris,  and  am 
bound  to  say  that,  while  in  some  cases  the  evils  spoken  of 
existed,  in  the  greater  number  of  instances  good  and  firm 
stumps  were  formed.  This  was  especially  the  case  in  several 
which  I  saw  in  M.  Lenoir's  service,  in  the  Neckar.  Some 
of  the  cases  which  had  been  operated  on  in  the  Crimea  were 
certainly  very  bad.  At  the  Society  of  Surgery  I  saw  an 
Arab,  shown  by  Baron  Larrey,  both  of  whose  limbs  had 
been  removed  above  the  malleoli,  in  the  East.  They  were 
both  secondary  operations,  and  seemed  to  have  healed  well 
at  first ;  but  the  cicatrix  afterward  ulcerated,  and  at  the  pe- 
riod he  was  shown  to  the  society  (nearly  two  years  after 
operation)  he  could  not  use  his  stumps  in  any  way,  from 
their  being  in  an  unhealthy  condition.  In  another  case, 
shown  to  the  same  society  on  a  subsequent  occasion,  the 
operation  had  been  performed  in  1848,  and  the  man  had 
been  an  inmate  of  hospitals  on  several  occasions  during  the 
interval,  on  account  of  ulceration,  abscesses,  and  necrosis  in 
his  stump.  The  bones  were  much  thickened,  and  evidently 
diseased  at  the  time  I  saw  him.  A  letter  from  M.  Hutin  of 
the  Invalides,  which  was  at  the  same  time  read,  stated  the 
results  of  the  operation  as  they  had  come  under  his  observa- 
tion, and  certainly  his  evidence  was  not  favorable ;  however, 
the  want  of  a  properly  constructed  artificial  limb  for  the 
patients  detracted  much  from  the  value  of  his  remarks.* 

*  Larrey  lost  several  of  his  low  amputations  by  tetanus,   which 
must  have  been  a  mere  coincidence.    Ballingall  tells  that  "  of  34  sol- 


AMPUTATIONS.  343 

If  the  limb  cannot  be  fitted  with  a  false  foot,  but  made  to 
rest  on  the  knee,  scarcely  anything  will  make  amends  for 
the  long  and  cumbrous  stump.  Since  1845  M.  Hutin  had 
had  5  cases  especially  under  his  notice:  one  could  walk, 
but  with  difficulty,  and  would  willingly  part  with  his  foot; 
one  had  been  several  times  in  hospital  from  the  state  of  his 
stump,  and  three  had  to  undergo  subsequent  amputation. 
Now  all  this  is  sufficiently  distressing  and  discouraging,  but 
in  military  practice  I  question  whether  it  is  conclusive.  The 
limited  mortality  yet  presents  itself  to  us  as  a  great  fact, 
which  arrests  our  attention.  If  when  men  die  so  fast  after 
the  ordinary  amputation  of  the  leg,  as  they  did  during  the 
early  part  of  the  war  in  the  Crimea,  it  becomes  a  grave  con- 
sideration whether,  with  all  its  subsequent  drawbacks,  we 
should  not  adopt  this  process  when  practicable.  If  our 
choice  lay  between  two  operations  of  equal  gravity,  then 
unquestionably  we  are  bound  to  select  that  which  will  pro- 
vide the  most  useful  stump;  but  when  the  chances  of  death 
are  beyond  all  comparison  greater  in  the  one  case  than  in 
the  other  —  when,  independently  of  those  dangers  which 
attach  to  the  operation  itself,  the  marked  presence  of  a 
hospital  epidemic  makes  it  desirable  to  expose  as  small 
and  as  rapidly-healing  a  surface  as  possible,  then  I  think  it 
may  be  conceded  that  the  sus-malleolaire  operation  has 
many  claims  upon  us.  Life  must  be  our  chief  concern, 
convenience  a  subordinate  consideration.  The  complaints 

diers  admitted  into  the  Invalided,  after  the  Russian  campaign,  with 
their  legs  amputated  immediately  above  the  ankle,  '2'2  had  such  bad 
stumps  as  to  induce  them  to  submit  to  a  second  amputation  below 
the  knee."  I  heard  Huron  II.  Larrey  inform  the  Societe  do  rhirurgie 
that  the  Russian  surgeons  employed  in  the  same  campaign  had  in- 
formed him  that  hospital  gangrene  being  very  rife  in  their  army,  they 
adopted  the  low  op.-rat  ion,  so  as  to  leave  room  for  a  subsequent  one 
if  the  stump  went,  wrong!  In  the  text  I  have  alluded  to  the  use  of 
the  operation  for  injury  only.  It  is  not  thought  applicable  to  casea 
of  malignant  disease  of  the  foot,  from  its  near  neighborhood  to  the 
:iffeHed  p-irt. 


344  SURGERY    OF   THE   CRIMEAN    WAR. 

of  patients  about  the  inconvenience  of  their  stumps  must  be 
considered  as  affording  little  evidence  in  the  matter,  as  the 
fact  that  they  survive  to  murmur  is  often  due  to  the  very 
operation  against  which  they  complain. 

If  the  heel  remains,  then  this  operation  could  not  be 
thought  of;  but  it  is  in  those  cases,  sufficiently  frequent  in 
their  occurrence,  in  which  the  whole  foot  has  been  carried 
away  by  round  shot,  or  such  like  accident,  and  in  which  the 
choice  of  operation  lies  only  between  the  amputation  above 
the  malleoli  or  higher  up,  that  the  merits  of  this  method 
can  be  weighed.  The  careful  study  of  those  cases  in  which 
caries  or  necrosis  has  appeared  in  the  bones  of  the  stump, 
after  the  sus-malleolaire  amputation,  will  be  found  to  have 
been  submitted  to  operation  for  disease,  and  not  for  injury, 
and  it  will  generally  be  found,  besides,  that  a  faulty  appa- 
ratus has  been  used  afterward.  Everything  depends  on  the 
careful  adaptation  of  the  false  foot,  and,  so  far,  this  is  of 
itself  an  objection  to  the  operation  being  performed  on  the 
poor ;  but  the  view  alone  I  wish  to  take  of  it  at  present  is 
with  reference  to  military  practice,  and  there  it  seems  to 
promise  many  advantages  at  times  when  there  prevails  a 
high  mortality  after  operations. 

Amputation  at  the  ankle-joint  was  performed  12  times 
in  the  Crimea  during  the  period  embraced  by  the  returns, 
and  death  followed  in  2  cases.  Of  the  total  number  of  cases 
3  were  secondary  operations,  and  these  were  all  successful. 
Syme's  operation  was  as  useful  and  as  successful  in  its 
results  as  usual.  Pirogoff's  modification  of  Syme's  method 
was,  I  understand,  several  times  tried  at  Scutari.  I  saw 
none  of  these  cases,  and  am  ignorant  of  the  results.  In 
England  it  appears  to  have  been  recently  followed  by  good 
effects  in  6  out  of  9  cases  in  which  it  was  performed.  Lan- 
genbeck  is  said  to  approve  of  its  results  in  a  good  many 
cases  in  which  he  has  tried  it ;  but  the  history  of  the  3  cases 
first  reported  by  M.  Pirogoff  himself,  and  those  more  recently 
put  on  record  by  Michaelis,  of  Milan,  and  various  German 


AMPUTATIONS.  345 

surgeons,  does  not  hold  out  much  encouragement  to  repeat 
the  operation,  not  only  from  the  long  period  necessary  to  a 
cure,  but  also  from  the  unsatisfactory  nature  of  the  resulting 
member.  It  was  reported  in  the  East  that  this  operation 
had  been  frequently  performed  by  Pirogoff  himself  in  Sebas- 
topol,  but  that  he  had  found  the  calcaneum  act  as  a  foreign 
body  in  the  stump,  and  was  hence  disposed  to  abandon  it. 
Roux  of  Toulon's  operation  was  performed  once  in  the 
general  hospital  in  camp,  with  most  excellent  results.  The 
chief  objection  to  this  operation  arises  from  the  vessels  and 
nerves  being  drawn  under  the  bone  ;  however,  it  certainly 
enables  us  to  form  a  stump  little  inferior  to  Syme's,  when 
the  half  of  the  heel  has  been  destroyed.  Baudens  is  said 
to  recommend  the  flap  to  be  taken  from  the  anterior  surface 
of  the  joint,  or  even  from  its  external  surface,  if  it  can  lie 
got  no  other  where,  rather  than  go  above  the  ankle.  Cho- 
part's  operation  was  performed  primarily  t  times,  one  case 
ending  unfavorably,  while  Lisfranc's  was  successful  in  the  4 
cases  in  which  it  was  tried.  The  step  now  always  followed 
by  Mr.  Ferguson,  of  removing  the  projection  of  the  astrag- 
alus in  performing  Chopart's  operation,  is  an  undoubted 
improvement. 

The  upper  extremity  has  been  removed  at  the  shoulder- 
joint,  between  the  1st  of  April,  1855,  and  the  end  of  the 
war,  39  times,  with  a  fatal  issue  13  times,  or  33*3  per  cent. 
Of  these  operations  33  were  primary,  and  9  deaths  followed, 
giving  thus  a  mortality  of  21  '2  percent;  while  of  6  secondary 
operations  4  died,  or  66  -6  per  cent.  During  the  previous 
period  of  the  war,  at  least  21  other  cases  of  amputation  at 
this  joint  were  performed,  beyond  the  39  mentioned  above, 
and  of  that  number  6  died,  thus  presenting  a  total  of  60 
cases  and  19  deaths,  or  a  ratio  of  mortality  of  31  '6  per 
cent,  overhead.* 


*  The  mortality  following  this  operation  is  shown  in  the  following 
table.     Larrey  is  s;ii<l  to  have  had  upwards  of  00  recoveries  from 


346 


SURGERY   OF    THE   CRIMEAN   WAR. 


It  is  impossible  fairly  to  contrast  the  results  of  amputation 
at  the  shoulder  and  that  in  the  shaft  of  the  humerus,  as, 
in  military  practice  particularly,  it  very  much  oftener  happens 
that  the  trunk  has  suffered  severely  in  those  injuries  which 
necessitate  exarticulation  than  those  in  which  amputation  of 
the  upper  arm  alone  is  required.  Not  a  few  illustrations  of 
this  occurred  in  the  Crimea.  Thus,  in  at  least  two  of  the 
cases  returned  as  shoulder-joint  amputations,  besides  the  in- 

about  100  cases  on  which  he  operated,  and  this  success  he  attributes 
to  his  method  of  operating. 


Amputation  at  the  shoulder. 

Pri- 
mary. 

No.  of 
deaths. 

Second- 
ary. 

No.  of 
deaths. 

Ratio 
mortality 
per  cent. 

Crimea,  after  April  1,  1855 
French,  Dolma  Batchi  Hos- 
pital                     .       .    . 

33 

3 

9 
1 

6 
6 

4 
.      3 

33-3 
44  4 

India  

4 

1 

25-0 

Sedillot    Constantine 

2 

2 

100-0 

Larrey,  (fils,)  Antwerp  
4.1cock    Spain 

5 
9 

1 

3 
1 

2 
] 

25-0 
20-0 

Guthrie    Spain 

19 

1 

19 

15 

42-1 

"         Waterloo 

6 

1 

12 

6 

38-8 

Roux    1848  

3 

1 

33-3 

Larrey,  Gross-caillou,  1880 

INJURY. 

Xew  Vork  Hospital 

3 

2 
7 

1 
6 

50-0. 
'   64.2 

Glasgow    Lawrie 

3 

2 

1 

50-0 

M'Ghie,   1842-53 

17 

6 

5 

3 

40-9 

Malgaigne  also  reports  7  cases,  all  ending  fatally,  but  does  not  indi- 
cate whether  they  were  primary  or  secondary  operations.  If,  then,  we 
sum  up  all  the  cases  in  this  table,  we  find  that  the  ratio  of  mortality  is 
20-2  for  primary  operations  performed  in  the  field,  and  Go  for  second- 
ary ;  while  both  operations  in  the  field  yield  a  mortality  of  36-8  over- 
head. If,  on  the  other  hand,  we  calculate  the  operations  for  injury 
alone,  then  those  performed  early  give  a  ratio  of  mortality  of  40-7  per 
cent,  and  the  secondary  69  per  cent. ;  while  overhead  operations 
for  injury  give  an  average  mortality  of  50  per  cent.,  and  primary  and 
secondary  operations,  for  both  gunshot  wounds  and  civil  accidents 
combined,  yield  a  total  average  mortality  of  39-8. 


AMPUTATIONS.  3'4Y 

jury  to  the  arm,  the  scapula  was  carried  away  or  destroyed, 
and  the  muscles  of  the  chest  torn. 

In  no  operation  is  the  advantage  of  primary  over  second- 
ary amputation  so  evident  as  in  that  at  the  shoulder-joint, 
early  operation  at  this  part  being  an  exceedingly  successful 
undertaking,  while  late  interference  generally  affords  a  con- 
siderable mortality.  Thus,  if  we  take  Outline's  experience 
in  Spain,  and  Dr.  Thomson's  observation  after  Waterloo 
alone,  this  point  is  well  illustrated  ;  of  19  cases  of  secondary 
amputation  mentioned  by  Guthrie  as  having  Urn  performed 
between  June  and  December,  1813,  15  died,  while  of  an 
equal  number  who  were  operated  on  in  the  field  only  1  died. 
Dr.  Thomson  again  says:  "In  Belgium  almost  all  of  tho>e 
recovered  who  had  undergone  primary  amputation  at  the 
shoulder-joint,  while  fully  one-half  died  «.f  those  on  whom  it 
lierame  necessary  to  operate  at  a  late  period."  The  same 
point  is  illustrated  to  >o:ne  ext'-nt  by  our  ( 'rim-'an  results, 
less  than  a  third  of  the  primary  and  two-thirds  of  the 
secondary  perishing. 

Deputy- Inspector  Gordon  had  one  case  of  recovery,  in 
whieh  both  the  arm  and  the  greater  part  of  the  scapula  were 
removed,  Mr.  Howard,  of  the  2()\\\  Uegim-nt.  successfully 
removed  the  right  arm  of  one  man  and  the  left  of  another, 
in  rlosr  succession,  at  tin- joint,  for  injury  occasioned 'by  the 
same  cannon-ball,  which  had  struck  between  them.* 

*  The  following  is  a  ino^t    i;  ns   slinking  how  the 

Operation  Of  imputation  ft!  the  shoulder  may  l>e  recovei  -i-'l  IVi'iu  under 
the  most  unpromising  eireumstances.      It  o.-rurred  in  tin-  :J'.Mli  Ke^i 
merit,  serving    in     India,   ami   under    the    care   of    Deputj-InepectOf 
TM\I«T.     St-i-rant  Itiidii.-  k  by  a  cannon- bull  on  the  upper 

]i:n-i  i)i'  liis  h-f'i  arm,  bj  which  the  bone,  including  the  bead  ami  upper 

third  of  tin-   huiiHM-ii  i-ln-il.      I'xitli    folds  of  the   axilla  wt-re 

carri"d    away,  and   the  artery  was   divided.      The  arm  was  only  kept 
attached    by  a  portion   of  tlu>   deltoid    and    the   skin   e.-vrniig  it.  and 
of  these  the  Haps  were  made.      This  man  1-iy  exposed  on  the  fndd  for 
•   he  recovered   emi-plcn-ly.       u  B  peculiar  in 


348  SURGERY   OF   THE   CRIMEAN    WAR. 

Amputation  of  the  upper  arm  was  performed  in  the 
Crimea,  from  April  1st  to  the  end  of  the  war,  102  times,  fol- 
lowed by  death  in  25  cases,  the  mortality  per  cent,  being  thus 
24'5.  Of  the  total  number,  96,  and  22  deaths,  were  primary 
operations.  The  ratio  of  the  mortality  was  thus  22  9  for 
the  primary,  and  50  0  for  the  secondary  operations. 

The  forearm  was  amputated  during  the  same  period  52 
times  primarily,  and  the  hand  at  wrist  once,  with  only 
one  death ;  while  of  7  secondary  operations,  in  the  same 
parts,  2  died. 

These  returns  do  not  speak  of  a  considerable  number  of 
secondary  amputations  of  the  arm,  which  were  performed 
early  in  the  war,  and  the  success  of  which  was  certainly  such 
as  to  warrant  us  in  trying  to  save,  in  the  first  instance,  most 
cases  of  gunshot  wounds  of  the  arm.  It  is  almost  impossi- 
ble to  say  what  wound  of  the  arm  by  a  ball  will  not  recover; 
so  that  it  is  a  well-recognized  rule  to  wait,  in  all  but  desper- 
ate cases,  and  only  amputate,  if  unavoidable,  at  a  subsequent 
period.  In  military  practice,  secondary  amputations  are 
only  justifiable  when  performed  on  the  upper  extremity. 

The  mode  of  managing  stumps  in  the  East  was  that  usu- 
ally followed  at  home  for  the  promotion  of  adhesion  by  the 
first  intention.  The  edges  of  the  flaps  were  usually  united 
by  suture.  The  observation  of  this  method  in  the  Crimea 
did  not  certainly  appear  to  be  satisfactory.  To  wait,  as 
Liston  so  strongly  advocates,  till  all  oozing  has  ceased  from 
the  cut  surface,  is  unquestionably  a  most  useful  precaution, 
and  one  of  great  moment  to  their  successful  and  early  union. 
The  irritation  which  the  stitching  of  the  edges  occasions, 
the  want  of  sufficient  room  for  subsequent  swelling,  the  con- 
finement of  pus  which  is  thereby  favored,  all  appear  reasons 

two  respects:  1st,  no  ligature  was  needed;  and,  2d,  at  least  two- 
thirds  of  the  face  of  the  stump  was  the  surface  left  by  the  passage 
of  the  cannon-ball,  and  yet  it  healed  very  kindly."  Dr.  Taylor  in- 
forms me  that  he  recently  saw  this  man  in  good  health.  He  is  on  the 
stuff  in  Belfast. 


AMPUTATIONS.  349 

against  sutures.  Stripes  of  wet  lint  applied  like  adhesive 
plaster  always  appeared  preferable.  I  never  saw  one  case 
among  our  most  numerous  amputations  in  which  primary 
adhesion  took  place  throughout  the  whole  surface  of  the 
flaps.  They  united  readily  enough  along  their  edges  ;  but 
the  result  of  this  was  that  a  large  bag  of  pus  was  formed 
within  the  end  of  the  stump,  which  continued  as  a  depot  for 
absorption  into  the  system,  by  steeping  the  end  of  the  sawn 
bone  and  the  vessels  in  its  matter,  and  it  burrowed  far  and 
wide  in  the  intermuscular  spaces  and  along  the  bone,  and 
ended  not  unfrequently  in  causing  considerable  necrosis  of 
the  end  of  the  divided  shaft.  Unquestionably  it  may  be 
said  that  such  collections  should  have  been  recognized  and 
prevented  ;  but  yet  it  seems  to  me  that  when  ample  proof  is 
afforded,  as  it  was  early  in  the  East,  that  primary  adhesion 
was  the  rare  exception,  and  not  the  rule,  and  when  the  pa- 
tients were  so  peculiarly  liable  to  purulent  absorption  as  they 
were  with  us,  it  would  have  been  better  practice  not  to 
have  attempted  primary  union,  but  to  have  adopted  such 
treatment  as  best  favored  the  freest  discharge  of  the  matter 
so  soon  as  it  was  formed. 

The  method  of  dressing  with  compresses,  recommended 
by  Mr.  Luke,  was  most  useful,  in  several  cases  in  which  I 
tried  it,  in  preventing  the  accumulations  referred  to.  The 
contrast  afforded  by  the  heavy  dressings  for  stumps,  em- 
ployed by  the  French,  and  our  water  dressing,  was  very 
marked,  and  may  have  contributed  something  to  the  result 
which  obtained  in  the  less  prevalence  of  purulent  absorption 
in  our  hospitals  than  with  them.  Bad  as  it  was  with  us,  it 
never  became  the  terrible  epidemic  it  was  in  the  French 
hospitals.  We  had  no  means  of  trying  the  method  of  treat- 
ing stumps  in  water,  recommended  by  Langenbeck.  The 
ease  with  which  the  purulent  secretion  can  be  got  quit  of  by 
position,  in  amputations  of  the  arm  and  leg,  contributes,  I 
have  no  doubt,  not  a  little  to  the  decreased  mortality  attend- 
ing these  operations,  as  compared  to  amputations  of  the 

30 


350          SURGERY  OP  THE  CRIMEAN  WAR. 

thigh.  The  Russian  surgeons,  I  am  told,  when  operating 
by  the  circular  method,  which  they  generally  adopt,  split  the 
posterior  flap,  and  keep  this  part  open  in  order  to  drain  off 
the  pus.  Such  a  step  would  meet  with  little  favor  in  this 
country,  but  it  presents  many  advantages  when  purulent  ab- 
sorption is  so  common  as  it  was  in  the  East.  M.  Se'dillot, 
of  Strasburg,  I  believe  proposes  a  similar  modification  for 
general  use. 

Primary  adhesion  is,  of  course,  most  desirable  when  hos- 
pital gangrene  prevails,  but  it  is  just  at  such  a  time  that  this 
result  is  most  difficult  to  obtain. 

Cases  of  secondary  amputation  of  the  thigh  for  injury  of 
the  knee  were  always  those  in  which  attempts  at  primary 
union  did  worst.  The  long  fusiform  collections  of  matter, 
which  are  so  apt  to  exist  in  these  cases  previous  to  opera- 
tion, extended,  and  did  every  possible  harm.  Careful  band- 
aging from  above  downward  to  the  base  of  the  flap  seemed 
to  be  highly  useful  in  these  cases.* 

Pus  poisoning  was  unquestionably  the  chief  source  of  our 
mortality  in  the  East,  after  amputation,  especially  after  sec- 
ondary operations.  The  resemblance  between  its  early  feat- 
ures and  those  of  ague  was  perhaps  more  marked  among 
our  patients  than  it  even  usually  is.  This  seemed  especially 
the  case  among  men  who  had  served  during  the  early  part 
of  the  war — of  this,  however,  I  am  not  certain.  We  had 
many  most  beautiful  examples,  post  mortem,  of  veins  leading 


*  Sir  Charles  Bell  strongly  advocated  the  bandaging  of  stumps, 
"to  compress  the  veins  and  cellular  membrane,  so  that  the  adhesive 
inflammation  in  the  mouths  of  the  veins  may  prevent  the  inflam- 
matory action  on  the  face  of  the  stump  from  being  communicated  to 
the  great  vessels.  The  great  vein,"  he  says,  "being  properly  com- 
pressed, adheres,  and  otherwise  it  lies  loose  and  open,  and  the  in- 
flammation of  the  general  surface  will  be  communicated  to  it."  It  is 
not  for  this  reason,  but  to  oppose  the  burrowing  of  matter,  and  to 
prevent  muscular  contractions  and  the  protrusion  of  the  bone,  that 
it  is  now  adopted. 


AMPUTATIONS.  351 

from  the  stump  remaining  round,  patulous,  and  filled  with 
pus,  and  sometimes  reddened  in  their  interior.  It  was  not 
uncommon  to  trace  the  pus-filled  vein  from  the  thigh  to  the 
vena  cava. 

It  is  a  question  on  which  it  is  difficult  to  decide  whether 
or  not,  when  pus  absorption  is  so  common  as  it  was  with  us, 
it  would  not  be  justifiable  practice  to  ligature  the  chief  vein 
at  the  time  of  operation.  The  views  of  Mr.  Travers  and 
others  would  certainly  seem  to  oppose  the  adoption  of  such 
a  step,  but  we  have,  on  the  other  hand,  the  evident  absorp- 
tion of  pus  into  the  system  by  this  channel ;  and,  besides, 
numerous  cases  are  on  record  in  which  the  ligature  of  the 
vein  has  not  only  not  been  followed  by  evil  results,  but  has 
absolutely  been  the  apparent  cause  of  preventing  inflamma- 
tion and  pus  absorption.*  The  non-appearance  of  symp- 
toms of  purulent  poisoning  till  after  the  separation  of  the 
threads  makes  it  generally  difficult  to  say  which  set  of  ves- 
sels— those  ligatured  or  those  not  ligatured — have  been  the 
carriers  of  the  pus.  In  the  case  referred  to  in  the  note 
death  took  place  rapidly,  before  the  ligatures  were  detached. 
Hennen  expresses  himself  thus  on  the  danger  of  tying  veins  : 
"When  the  great  veins  bleed  I  have  never  hesitated  about 
tying  them  also,  and  it  is  most  particularly  necessary  in  de- 
bilitated subjects."  Chevalier,  too,  says :  "  I  know  from  ex- 
perience that  the  principal  vein  of  a  limb  may  be  included  in 
the  same  ligature  as  the  artery  without  any  disadvantage 
ensuing."  Every  hospital  surgeon  has  seen  instances  of  the 
same  thing.  I  most  firmly  believe  in  Stromeyer's  views  on 
absorption  by  the  veins  of  the  bone,  from  observations  which 
have  been  presented  to  me. 

Independently  of  all  fortuitous  circumstances,  there  can 

*  This  is  particularly  well  illustrated  in  a  case  related  by  Mr. 
Johnston,  of  St.  George's  Hospital,  in  the  journals  of  1857.  In  that 
case  those  vessels  which  had  been  tied  were  free  both  of  inflamma- 
tion and  pus,  while  those  not  included  in  ligatures  were  full  of  pus, 
and  "much  inflamed." 


352  SURGERY    OF   THE    CRIMEAN    WAR. 

be  little  doubt  but  that  some  constitutions  oppose  themselves 
more  to  pus  poisoning  than  others.  This,  although  a  most 
unsatisfactory  mode  of  explanation,  yet  seems  the  only  way 
of  answering  the  difficulty  which  is  presented  to  us  in  the 
much  greater  susceptibility  of  some  to  purulent  absorption 
than  others.  Most  die  rapidly,  while  others,  not  apparently 
so  well  fitted  to  withstand  the  assaults  of  such  an  invader, 
though  placed  in  precisely  the  same  circumstances,  only 
yield  inch  by  inch,  and  others  again  escape  altogether. 

The  presence  of  typhus  fever  in  a  hospital  has  been  sup- 
posed to  favor  the  development  of  pyaBmia,  and,  although  it 
cannot  be  denied  but  that  the  diseases  often  coexist,  yet  it 
seems  more  probable  that  they  both  proceed  from  a  like 
source — a  lowered  vital  energy  in  the  patients,  or  vitiated 
hygienic  arrangements. 

The  secondary  deposits  were  with  us,  as  usual,  generally 
found  in  the  lungs.  Beck  states,  as  the  results  of  his  observ- 
ation in  Holstein,  that  such  was  the  seat  of  the  deposition 
in  seven  cases  out  of  ten  in  which  patients  died  of  pyaemia- 
This  is  not,  I  believe,  an  exaggerated  average.  Some  of 
the  French  surgeons  employed  at  Constantinople  made  the 
remark  that  they  seldom  found  the  pus  collected  in  depots, 
as  they  had  been  accustomed  to  see  it  in  Africa ;  but  that  it 
commonly  was  disseminated  through  the  organs,  muscles, 
and  bones. 

The  visceral  congestions  which  so  often  follow  amputa- 
tion were  more  than  commonly  fatal  in  their  results  in  the 
Crimea,  from  the  presence  in  most  cases  of  the  seeds  of  dis- 
ease in  the  lungs,  kidneys,  and  intestines.  Phthisis  and 
acute  dysenteric  attacks  were  not  unfrequently  the  immediate 
causes  of  death,  and  in  at  least  two  cases  the  symptoms  of 
Bright's  disease  of  the  kidney  were  most  rapidly  developed 
after  thigh  amputations.* 

*  For  an  outline  of  the  statistics  of  the  French  army,  see  Appen- 
dix H. 


A  P  T  E  N  I)  I  X 


30* 


APPENDIX. 


APPENDIX  A. 

THE  following  summary  of  the  geology  of  the  allied  position 
is  from  a  Keport  published  by  Dr.  Sutherland,  the  Government 
Commissioner  to  the  seat  of  war  : — 

"The  geological  series,  from  above  downward,  includes  the 
following  formations  :  1.  The  newer  tertiary,  or  steppe  limestone. 
2.  Volcanic  cinders  and  ashes.  3.  The  older  tertiary.  4.  Num- 
mulitic  limestone.  5.  White  chalk  and  green  sand.  6.  Neoco- 
mien.  7.  Jurassic  limestone.  8.  Conglomerates.  9.  Schists.  10. 
Erupted  volcanic  rocks. 

"  1.  The  nev:er  tertiary  limestone  forms  the  superficial  stratifica- 
tion of  the  plateau  before  Sebastopol,  and  also  the  higher  levels 
of  the  country  to  the  north  and  northeast  of  Sebastopol  harbor. 
The  siege-works  were  principally  excavated  in  it.  This  limestone 
affords  good  rubble  building  stone,  and  also  an  inferior  road 
material. 

"2.  Immediately  under  the  upper  tertiary  beds  at  San  Georgeo 
is  a  bed  of  volcanic  ashes  containing  shells,  which  can  be  traced 
from  the  great  ravine  of  San  Georgeo  along  the  sea-coast  to  Cape 
Chersonese,  and  thence  round  the  inlets  of  Sebastopol  harbor  to 
Karabelnaia. 

"  3.  Older  tertiary  beds  underlie  the  volcanic  ashes  in  the  cliffs 
of  San  Georgeo.  They  come  to  the  surface  at  Karabelnaia,  and 
form  the  Heights  of  Jnkerman,  as  also  the  hills  bounding  the 
north  side  of  Sebastopol  harbor. 

(355) 


356  SURGERY   OF   THE    CRIMEAN    AVAR. 

"4-.  The  nummulitic  limestone  forms  the  hill-slopes  and  cliffs  of 
Inkerman,  in  the  ravines  of  which  it  has  been  extensively  quar- 
ried for  building  stone.  The  hill-slopes  above  the  quarries  are 
covered  with  loose  nummulites.  The  formation  again  appears  in 
the  hills  at  the  head  of  Sebastopol  harbor,  extending  from  thence 
to  the  northeast  of  the  line  of  Mackenzie's  Heights. 

"5.  The  white  chalk  begins,  on  the  west,  at  the  ruins  of  Inker- 
man, where  it  is  mixed  with  green  particles  and  upper  green 
sand  fossils.  It  forms  the  line  of  cliffs  and  tains  of  Mackenzie's 
Heights  :  also  the  bed  of  the  lower  valley  of  the  Tchernaya,  and 
occupies  the  area  between  the  slopes  of  Mackenzie's  Heights  and 
the  ridge  which  separates  that  valley  from  the  basin  of  Balaklava. 
It  extends  eastward  along  the  base  of  the  heights,  and  fills  up 
the  space  between  them  and  the  Jurassic  limestone  group  east  of 
Tchorgoun,  rising  into  round-backed  lofty  hills.  It  forms  also 
the  line  of  hills  south  of  the  Tchernaya,  known  as  '  Fedoukine 
Heights.' 

"6.  Neocomien  beds  appear  under  the  chalk  near  Tchorgoun, 
and  extend  along  the  western  side  of  Schula  valley  toward  Aitodar. 

"  7.  Jurassic  limestone  appears  on  the  west,  in  the  great  cliff 
at  the  ravine  of  San  Georgeo.  It  forms  the  sea-coast  cliffs  and 
mountain  chains  to  the  eastward,  and  also  the  mountain  groups 
between  the  valley  of  Tchorgoun  and  the  Baidar  and  Varnoutka 
basins.  The  rock  is  much  altered,  dislocated,  stratified,  hard, 
and  compact,  often  fissured,  and  the  fissures  filled  with  indurated 
red  clay.  Not  unfrequently  it  caps  the  conglomerate. 

"8.  Conglomerates  of  different  degrees  of  fineness  occur  from 
the  ravine  of  San  Georgeo  to  Baidar  valley.  Fine-grained  beds 
of  conglomerate,  apparently  altered  by  heat,  underlie  the  Jurassic 
cliff  at  San  Georgeo.  Immediately  to  the  northeast  of  the  cliff 
the  formation  reappears,  and  forms  part  of  a  chain  of  hills  closing 
the  upper  end  of  the  valley  of  Karani.  The  hill  on  the  south  side 
of  the  entrance  to  the  valley  above  the  bazaar  at  Kadikoi  also 
consists  of  the  same  formation.  Marine  Heights  and  the  hills  to 
the  east  are  wholly  or  partially  formed  of  conglomerates,  as  are 
also  the  southern  and  western  slopes  of  the  Varnoutka  basin. 
Part  of  the  mass  of  Cape  Aia  consists  of  the  same  rock. 

"9.  Schists,  apparently  belonging  to  the  Lias,  underlie  the  con- 
glomerate beds  in  the  ravine  of  San  Georgeo.  They  reappear  on 
the  south  and  eastern  sides  of  the  basin  of  Balaklava,  under  the 


APPENDIX.  357 

Col,  and  in  the  ridge  separating1  Balaklava  basin  from  the  valley 
of  the  Tchernaya.  They  are  found  in  large  masses  in  the  valleys 
to  the  east  of  Kamara,  from  whence  they  extend  southward  to 
the  sea-shore.  They  occur  in  the  basins  of  Varnoutka  and 
Baidar,  and  in  the  undercliff  below  Laspi. 

"10.  Erupted  volcanic  rocks  form  the  vast  picturesque  masses 
of  Cape  San  Georgeo.  They  underlie  the  upper  and  lower  ter- 
tiaries  there,  and  they  protrude  themselves  at  intervals  among 
the  Jurassic  limestones-  and  schists  along  the  south  coast  of  the 
Crimea  to  the  eastward." 


APPENDIX  B. 

"  Observations  were  kept  irregularly  by  various  persons  in 
Balaklava,  but  there  was  no  regular  series  except  those  kept  at 
the  Castle  hospital  by  Drs.  Jephson  and  Matthew.  The  instru- 
ments made  use  of  were  an  aneroid  barometer,  a  maximum  and 
minimum  thermometer,  a  wet  and  dry  bulb  thermometer,  by 
Negretti  and  Zambra,  a  sun  thermometer  and  an  air  thermom- 
eter. The  instruments  were  placed  on  the  north  side  of  one  of 
the  huts,  about  320  feet  above  the  sea,  and  overhanging  it.  From 
this  circumstance,  and  from  partial  observations  elsewhere,  it  is 
probable  that  the  Castle  hospital  observations  represent  a  sea 
climate  rather  than  a  land  climate;  that  the  mean  temperature 
in  the  close  land  locked  harbor  of  Balaklava,  with  its  overhang- 
ing mountain  slopes  reflecting  the  sun's  rays,  was  higher  than  at 
the  Castle  hospital,  at  least  during  summer ;  and  that  the  ex- 
tremes of  heat  and  cold,  as  well  as  of  dryness,  were  greater  on 
the  plateau  before  Sebastopol. 

"  The  highest  observed  sun  temperature  was  on  the  14th  Au- 
gust, 1855,  on  which  day  the  sun  thermometer  indicated  125°  F. 
The  highest  observed  shade  temperature  was  99°  F.,  on  the  23d 
July;  and  the  lowest  observed  temperature  was  2-5°  F.,  oil  the 
19th  December,  1855. 

"  On  comparing  the  climate  of  the  allied  occupation  with  that  of 
the  metropolis  for  a  series  of  years,  we  find  that  in  April,  1855, 
the  excess  of  mean  temperature  at  Balaklava  over  Greenwich 
was  3-8°  F.;  in  May,  9'5°  F.;  in  June,  11-9°  P.;  in  July,  11'3° 
F. ;  and  in  August  the  excess  was  11  9°  F.  In  September,  1-8° 


358  SURGERY   OP    THE    CRIMEAN   WAR. 

F. ;  in  October,  9-4°  F.;  in  November,  4-6°  F.;  in  December,  the 
Crimean  temperature  wes  7*1°  F.  under  the  London  mean  of  the 
month.  It  was  1-7°  F.  above  the  London  mean  in  January,  1856. 
In  February  it  was  2 '6°  below  the  London  mean,  and  9*2°  F. 
below  the  same  mean  in  March.  In  April  the  Crimean  temper- 
ature showed  an  excess  of  1-4°  F.,  and  in  May,  of  7'5°  F.  above 
the  London  mean. 

"The  daily  mean  range  of  the  month  was  in  excess  of  that  of 
Greenwich.  In  April,  1855,  the  excess,  was  -f-  4-4°;  in  May, 
+  4-1°;  in  June,  -f-4-l°;  and  in  July,  -f  5'4°.  In  August  it  was 
+  4-5°;  in  September,  +1-8°;  in  October,  +5-1°;  in  Novem- 
ber, -f  3°;  in  December,  -f  2-3°.  In  January,  1856,  it  was 
-f  1-2°;  in  February,  +1-9°;  in  March,  -fl-50;  in  April,  +  1-2°; 
and  in  May,  -f  1-1°. 

"The  following  table  gives  the  monthly  means  and  ranges,  from 
April  1, 1855,  to  May  31, 1856,  as  deduced  from  the  observations 
kept  at  the  Castle  hospital,  Balaklava : — 


APPENDIX. 


359 


(       O  CO  Th  Cl 


OS  QO  iM  CO  OS 

c:  co  —>  C:  C-i 
'•9'  ^  O  CM  »O 


»s  10  en  CD  o 

rH  i-H  CM  CM  CM 


00 
O 


qTo  qs  o  t-  cs 

l^-  OO  »—  O  O  CO 


CO  CO  CO  -^ 


It 


CO  0  OS  0  05 

O  CO  ii  C:  71 
•<ti  co  co  o  ^> 


II 


toi     i-coopcMO^-ooqs 

^    v,S  »o  «D  5  ^  S  ^  w 


i-O 
CO 


i>60  SURGERY   OP   THE   CRIMEAN    WAR. 

"So  far,  then,  as  can  be  ascertained  by  the  observations,  the 
Crimean  climate,  during  the  period  of  the  allied  occupation,  may 
be  characterized  as  one  of  extremes, — intense  summer  heat  and 
sun  radiation,  and  severe  winter  cold.  The  observed  difference 
of  air  temperature  in  July  and  December  was  93'5°  F.;  and  the 
difference  between  the  highest  sun  temperature  and  the  lowest 
air  temperature  was  122-5°  F.  The  daily  variations  were  also  at 
times  excessive.  During  the  hot  season,  the  daily  maximum 
shade  temperature  ranged  from  72°  to  99°  F.,  while  the  minimum 
ranged  from  44°  to  72°  F.  The  sun  temperature,  to  which  the 
troops  were  exposed  day  after  day  during  the  same  season,  varied 
from  110°  to  125°  F.  The  passage  from  the  sunshine  to  the 
shade  was  attended  by  a  fall  of  temperature  of  from  32°  to  44°  F. 
A  sun  temperature  of  120°  F.  was  followed  by  a  fall  of  from  50° 
to  60°  F.,  at  the  minimum  period  of  the  same  night. 

"The  barometric  means,  so  far  as  could  be  ascertained  by  the 
aneroid  barometer,  were  steady,  and  the  range  under  one  inch. 

"The  rainfall  in  November,  1855,  was  3-167  inches,  all  of  which, 
except  less  than  half  an  inch,  fell  on  the  last  six  days  of  the 
month  There  was  a  little  snow  on  the  27th  Between  the  1st 
and  12th  December  there  fell  2-300  inches  of  rain.  There  was  a 
little  snow  on  the  13th,  and  six  inches  of  snow  on  the  17th  and 
18th  together.  During  January,  1856,  there  fell,  on  thirteen  days, 
2-499  inches,  and  about  seven  inches  of  snow  fell  on  the  4th,  5th, 
and  17th  of  the  month.  Snow  fell  on  eight  days  in  February,  the 
heaviest  fall  being  on  the  1st  of  the  month,  and  equivalent  to 
1  -294  inches  of  rain.  There  was  hardly  any  rain  during  the  month, 
but  the  total  fall  of  snow  was  equivalent  to  2'438  inches.  The 
greatest  cold  of  the  year  was  on  the  19th  December,  1855,  when 
the  minimum  temperature  was  as  low  as  2 -5°  F.  The  maximum 
of  the  same  day  was  9°  F.  The  mean  temperature  in  November 
was  48-9°;  in  December,  33-3°;  and  in  January,  1856,  40°  F." — 
Sanitary  Commission  to  the  East. 


APPENDIX  C. 

Table  by  Dr.  Christison,  showing  the  weight  and  nutritive  value 
of  each  article  issued  to  the  British  and  to  the  Hessian  soldier  as 
a  daily  ration  : — 


APPENDIX. 


361 


Ounces  of 

nutritive 
principle. 

Whereof  there  is 

Carl  ion  if- 
erous. 

Nitro- 
genous. 

British    sailor,    daily    nutriment 
exclusive  of  beer 

re- 
1 

28-5 
3296 

23-52 

20-90 
26-59 

166 

7-54 
6-37 

6-92 

Hessian  sailor,  daily  nutriment.. 
British   soldier   in  the  Crimea, 
ceiving  daily  — 
1  It)   salt  meat 

I 

2  oz   sugar                        

Coffee,  not  used  ;   rice,   uncer- 
tain ;  beer,  none. 

APPENDIX  D. 

"Return  showing  the  duty  performed  h 
1855  :— 


the  army  in  January. 


Kauk  and  file. 

Brigade 
of 

(Jnanl*. 

•J.1  Hi- 
vision. 

:M  Di- 
vision. 

4th  Di- 

vi.-inu. 

Light 

Division. 

Total. 

Effective  and  pres- 
ent under  arms.. 
Detailed    for    duty 
of  various  kinds 

948 
403 

2469 
827 

2668 
1170 

2332 
1431 

2770 
1190 

11,367 
3321 

"The  results  for  December  and  February  were  much  the  same 
as  in  January." — Col.  TuUoch,  p.  17G. 

APPENDIX  E. 

"The  routine  of  duty  in  particular  regiments  is  thus  described 
by  various  officers: — 

"Lord  West,  commanding  the  21st  Regiment,  states  that: — 

"'Those  for  the  day  covering  party  are  roused  out  of  their 

tents  at  4  o'clock  in  the  morning,  have  about  a  mile  and  a  half 

to  march  down,  through  snow  and  mud,  and  get  back  to  their 

csunp  about  7  o'clock  in  the  evening,  being  thus  exposed,  in  open 

31 


362  SURGERY   OF   THE   CRIMEAN   WAR. 

trenches  for  15  hours,  to  such  inclement  weather  as  now  prevails. 
Most  of  them  will  go  on  the  following  evening  at  5  o'clock,  and 
remain  out  all  night  till  6  o'clock  the  following  morning;  this 
routine  has  been  kept  up  incessantly  for  the  last  six  weeks.' 

"  Lieutenant-Colonel  Maxwell,  commanding  the  46th  Regiment, 
a  corps  which  was  nearly  annihilated  by  sickness  in  the  months 
of  November  and  December,  states  that  the  number  of  hours  his 
men  were  in  the  trenches  in  every  24,  was  12  in  the  first  of  these 
months,  and  10^  in  the  second;  and  it  was  stated  by  the  surgeon, 
and  verified  by  the  lieutenant-colonel,  that  at  one  time  the  men 
were  in  the  trenches  for  six  successive  nights,  and  had  only  one 
night  in  bed  in  the  course  of  a  week,  but  that  afterward  the 
duty  was  better  regulated. 

"  The  duties  in  the  Light  Division  are  thus  described  by  Dep- 
uty Inspector-General  Alexander,  in  a  letter  dated  10th  Decem- 
ber, 1854:— 

"  'In  the  7th  Fusiliers,  men  were  in  the  trenches  24 hours  with- 
out relief,  up  to  or  about  the  17th  November;  on  the  14th  two 
companies  were  kept  on  picket  for  36  hours,  when,  of  course,  no 
cooking  took  place. 

"  'In  the  19th  Regiment,  taking  the  total  number  of  hours  for 
November,  viz.,  720 — 304  have  been  passed  by  the  men  either  on 
duty  in  the  trenches,  or  on  picket,  which  is  10  hours  daily  for 
each  man,  the  remaining  fourteen  being  passed  in  bringing  water, 
seeking  for  fuel,  cooking,  and  other  duties,  etc.  In  the  23d 
Fusiliers,  the  average  return  gives  to  each  man  one  night  in  camp 
and  one  on  duty;  many  men,  however,  had  to  go  on  duty  with 
their  companies  two  or  three  nights  running,  doing  24  hours' 
duty  to  12  in  camp. 

"'In  the  34th  Regiment  the  men,  on  an  average,  were  some- 
thing less  than  one  night  in  their  tents,  with  water  and  fuel 
fatigues  when  off  duty;  they  are,  in  consequence,  weak  and 
wasted  from  the  incessant  and  severe  duty. 

"  'In  the  77th  Regiment  the  men  were  either  in  the  trenches 
or  outlying  picket  every  second  night;  on  the  intervening  days, 
guards,  besides  water  and  fuel  fatigues,  etc. 

" '  In  the  88th  Regiment  no  man  has  ever  more  than  one  night 
in  his  tent,  has  12  hours  in  the  trenches,  and  24  hours  on  picket, 
and  then  has  to  look  after  wood  for  cooking,  water,  etc.  etc.' 

"A  return  and  letter  from  Captain  Forman,  commanding  the 


APPENDIX. 


363 


right  wing  of  the  2d  battalion  of  the  Rifle  Brigade,  also  shows 
that  iu  November  that  wing  was  on  duty  17  times,  namely,  9  in 
the  trenches,  and  8  in  picket;  and  that  the  average  daily  duty 
performed  by  each  man  was  about  10^  hours,  in  addition  to  two 
hours  spent  in  going  to  and  from  the  trenches,  besides  the  fatigue 
of  procuring  wood  and  water,  and  other  regimental  duties. 

"  In  December  the  amount  of  duty  in  that  corps  is  described 
as  being  rather  less,  viz.,  only  about  9  hours  in  the  trenches  or 
pickets,  exclusive  of  other  duties. 

"  These  few  individual  instances  will  be  sufficient  to  show  how 
the  system  worked,  and  there  appears  no  reason  to  suppose  that 
(except,  perhaps,  in  the  46th  Regiment)  they  differed  from  the 
ordinary  routine  of  duty  in  other  corps  during  this  period." — 
TULLOCH,  Crimean  Commission,  pp.  177-78. 


APPENDIX  F. 

TABLE  giving  the  weight  of  the  different  balls  used  by  the  various  bcUi'j- 
erents  during  the  past  war.  With  the  exception  of  our  oicn  the  weights 
noted  can  only  be  looked  on  as  close  approximations,  from  the  specimens 
being  too  few  to  enable  the  weights  to  be  given  with  perfect  exactness.  All 
the  specimens  examined  were  new  balls  which  had  not  been  used. 


Description  of  ball. 

Average  weight. 

ENGLISH. 

1.  Large  conical  ball  with  a  cup. 
Ball  of  1851.  Used  now,  I  be- 
lieve  only  by  the  marines 

Ounces. 

Drachms 

Scruples 

Grains. 

i 
i 

i 

i'j 
iij 

i 

xiij 

X 

i 

V 
X 

ix 
xiv 

2    Do   without  the  cup  

3.  Ball  of  1853.     Longer  cone  than 
the  last.     The   Enfield  rifle-ball 
Hollow  in  the  base.     Coming  into 
universal  use  in  the  infantry  .  . 

ij 

u 

4.  Conical  ball  with  an  iron  cup. 
Same  size  as  the  last,  and  formerly 
used  for  the  same  rifle 

i 
i 

5    Old  round  musket-ball 

0.  Lancaster  ball.     Smitll  elongated 

vij 
i 

7.  Old  rifle-ball,  with  belt,  1842,  noi 
now  in  use 

i 

364 


SURGERY    OF   THE    CRIMEAN    WAR. 


Description  of  ball. 

Average  weight. 

FRENCH. 

1.    "Balle  a  culot."     Large  conical 
ball,  with  three  rings  and  a  deep 
cut.     Used  by  the  Zouaves  

Ounces. 

Drachms 

Scruples 

Grains. 

i 
i 
i 

vj 

ij 
v 

ij 
vj 

vj 
iv 
xvj 

xvj 
viij 

xvj 

2.   Minie  ball.     Used  by  the  grena- 
diers and  voltigeurs  of  the  guard.. 
3.   "Balle  carabine  a  tigne."     Used 
by  the  chasseurs  de  Vincennes  
4.  Small  conical  ball  of  the  artillery 
of  the  guard.     Two  deep  rings  

ij 

ij 

5.  Round  infantry  ball  

6.  Variety  of  last,  being  a  half  sphere 
with  a  hollow  base  —  not  so  much 
used 

i 

SARDINIAN. 

1.  Carabine  of  the  Bersagliere.  Con- 
ical ball,  with  solid  base,  and  com- 
ing rapidly  to  a  very  sharp  point 

jxss 

vij 
vj 

V 

vj 

V 

vj 
i 

i 

2.  A  short  flattened  cone,  similar  to 
No.   vj   of  the   French.     Cupped. 
Used  by  the  infantry 

XV 

xiij 
i 

3.  Large   pistol   ball,    used   by  the 

ij 

4.    "Ball  a  stilo."     A  large  conical 
ball,  with  a  solid  base  and  three 
rings                                         . 

i 

i 

i 

i 
i 
i 
i 
i 

RUSSIAN. 

1.  Long  conical  ball,  with  a  very  deep 
cup  in  the  base.      Three  shallow 
rings      Range  1200  yards     

2.  Liege  rifle-ball.    Conical,  flat  base 
Three  rings  and  two  raised  ribs  to 
fit  grooves  in  the  barrel      

iij 

3.  Conical  ball,  with  flat  base,  and 

4    Flattened  cone  with  a  cup 

ij 

xiv 

X 
XXV 

vj 

5    Same   only  a  smaller  size 

6    Same   only  a  smaller  size 

7    Round  musket-ball                         . 

Sometimes  two  of  these  round  balls 
were  united  by  wire,  so  as  to  resem- 
ble bar-shot,  and  produced  great  de- 
struction of  the  soft  parts. 

AIM'KNDIX. 


365 


Description  of  ball. 

Average  weight. 

TURKISH. 

1.  Round  ball  for  musket  with  flint- 
lock 

Ounces. 

Drachms 

Scruples 

Grains. 

V 
vj 

iv 
v 

y 

i 

**    Do   percussion 

iv 
*$ 

3.  Conical,  flat  base,  three  rings  for 
rifle              

i 

4.  Small  round.     Used  by  the  Bashi 

The  Russians  employed  ten  sizes  of  grape-shot,  varying  in 
weight  from  oz.  i,  3iv,  3ij,  and  gr.  xij,  up  to  the  enormous  "  whop- 
per," as  the  soldiers  termed  them,  whose  weight  was  Ib.  iij,  3ij, 
and  gr.  vj.  The  greater  number  of  the  sizes  intermediate  be- 
tween these  two  were  either  inclosed  in  canister  or  in  bags  of 
canvas,  or  fastened  round  a  spindle  of  wood.  The  largest  size, 
above  alluded  to,  was  screwed  between  segments  of  wood  con- 
taining hollows  fitted  to  receive  the  shot.  The  effect  produced 
by  this  grape  was  little  inferior  to  that  caused  by  round  shot. 


31* 


366 


SURGERY    OF   THE   CRIMEAN    WAR. 


TABLE  No.  1.  —  Showing  the  Mortality  following  the  Greater  Amputations  in  all  parts  for  Gunshot  Wounds. 

Total  ratio 
mortality 
per  cent. 

oo  o  to      ocoocoocoocoi—oo  <s?"tp  o  o  co  co  o  o 

i    58 

CD 

to 

-* 

333  ss8S3gss£gss3t~§§sw;3og 

Total 
deaths. 

§88  883g3*st-S8*M8g5°'o''o|o     33 

O 

Total 
cases. 

CO  CO  O  CO  <M  O  O              tOO 
HJ«N  tO  r-l  C5  O  CO              t-  tH 

1 

§<O  O        -^  2i  O  I-  :O  rl  SI  rH  1-  -f  rH  CO  C 
C^                            CO                                                      rH 

Mortality 
per  cent. 

ooo      o  o  -*  t-  o  o  o  o  o  o  o  o 

o  o  rH      rHcbrHi—  O-*GCO-*OOO 

CO  O  -*l<         O-?t<i-OOOCCOCOCOO<M 
|H               r-t 

o 

I) 

1 

i 

Deaths. 

SO  35  Cl        CO'MiOOOCOOOTt<-J<a5CO<M 
CO       •*       rH  O}       CO                        rH 

: 

o 
£l 

1 

Secondary. 
No.of  cases. 

SOD  (M        O  r-l  t~  >O  O  r-l  O5  •«*  rH  >O  O  00 
rH  O        COO        !M  r-l  i-<              -^  r-l 

1 

g 

i  ! 

Mortality 
per  cent. 

OOO        O  CC  O  •*  <£>  O  O  O  O  00  O  (^1 
l^T—t^         ^-OOfHCCOOOT—  IH*b-CO 
COCOCO         OO^rH^rHOtDCOO^CO 

CO  CO  O 
CO  0  CO 

CO 
0                    CO 

I 

Deaths. 

g-*0        t~Ol-rH05C002COMCOCOl-l 
i-l  O              i-t        CO                          <N  r-( 

IM  <M  CO 

s       s 

i 

Primary. 

No.  of  cases. 

oirato      ooc»or--tcoootoo5cci-i 
-t^.o          ^TJH-*O      i-ii-ieo<N      co 

SSS3 

S          5 

I 

S:   :  o       :   :   :   :           :    :   :   : 
•   •  **          :   :              :   :   : 
co    :    :    - 

14 

Aboukir  and  Camperdown  
Communicated  to  the  Academy  in  1848, 
in  winch  no  distinction  is  made  between 
primary  and  secondary  operations  
St.  Louis,  1832—  Kicherand  

Total  

^  Ml       i  i         1  ij 

1  15  H-?  e  I  i  « 

M    •§  §•        !  i  a  JS  1  1  b 

i  l:-i.a::r|Hi 

i    i-2 

1 

1  Campagne  Constantine  —  Sedillot  . 
Feroc  '.  
27th  and  29th  Brumaire—  Larry  ( 
Battle  of  Newbourg  —  Percy  
Fanni 

H  <(  i  M  E| 
sjli^   M  Ji,H* 

^3  S  2  oo  5}  af  J  JJ    r.D    :^4s-»*;^a> 
ggcCr-noOc    :"c!=!SxSrtcci2- 

iiiriliii^ii'liiii 

AL'l'KNUlX. 


361 


.5    P 


•S  g 


1  1 

-g  - 


cu 


I  g 

i! 
il 


d    oT 
<u  -S 

>    ^3 

'So  5 


^  J  ^ 
2  ^   fl 


-u     O 

^  ^a 


.8     ^ 


§3 


8  s 


I  P  1 


0>-    tn    ^   co 

fe    d         a 
^    o 


2  oo 

• 


0     C3     0    .*3 


•h-i 

f  U 

>        j=    0 

a! 

:  o  o  co  o  o  -*  cc 
•Z*  6s  o  >fi  -1*1  >'c  i'-  ^-  VD  i  :'? 

<O  CC  CO  ^5  ~f  -^  r-i  «C  —  *(  CO 

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C2          C  ••*• 

"o  tf  ^ 

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H  ** 

0          X    - 

||  Jl 

11 

rH  O5  O5  CC  35'  j-l  O  M  CO  00 

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rH"    °r-ll^?^       S 

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to 

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£;!  r|      S 

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f  i  ?   o       £ 

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,      ^H 

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^'~  >,~     £ 

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S 

5  •=  :=  _   ~ 

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1 

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p   O   ^  ^   >    ^, 

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:  :   :  :   • 

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:    ; 

6 

:.«           : 

|j 

ItlHl 

iw       i 

o  o  >>  ^  •*•*  o 

H 
•< 

;s's  Hospital—  Soutli 
r  College  Hospital  — 
.nfirniary  —  Lawrie.. 
"  Steele.., 
M'Ghie  . 
Elospital  —  Hussey  ... 

:'4—  Laroche  
ames  
setts  Uoapital—  Hay 

||l||| 

c  3  .-5"^         "« 

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Ill^lt 

S^PO     wS^ws 

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368 


SURGERY    OF    THE    CRIMEAN    WAR. 


APPENDIX  H. 

Since  the  completion  of  the  foregoing  volume,  a  work  has  ap- 
peared by  M.  Scrive,  inspector -general  of  the  French  medical 
service  in  the  Crimea,  from  which  a  few  details  are  added,  as 
bearing  on  the  medical  history  of  the  late  war. 

"In  four  months,"  says  M.  Scrive,  "47,800  men,  in  an  effective 
force  of  145,000,  entered  our  ambulances  during  the  winter  of 
1855-56;  9000  of  these  died;  an  equal  number  of  those  trans- 
ferred, perhaps,  perished  in  the  hospitals  at  Constantinople,  or  in 
France." 

TABLE  showing  the  cases  and  deaths  from  wounds  and  disease  in  the 
French  army  from  September,  1854,  to  July,  1856. 


Admissions 

Discharged. 

Transferred 

Dead. 

Officers  wounded   ordinary 

135 

104 

31 

"             "      by  gunshot. 
"       ill  of  fever             . 

1,625 
1,098 

740 
401 

770 
503 

115 
1941 

Soldiers  wounded,  ordinary. 
"             "     by  gunshot. 
"             "         frost-bite. 
Intermittent  fever  

5,582 
35,912 
5,596 
6,983 

3,168 
10,178 
2,012 
3,746 

2,154 
22,121 
3,472 
3,197 

2602 
3,6133 
112 
404 

Remittent  fever     

12,267 

4,036 

6,436 

1,795* 

Pernicious  fever  

275 

73 

52 

1506 

Typhoid  fever  

6  351 

1,060 

1,628 

3  6637 

Typhus  fever  

11  124 

1,266 

3,840 

6,018 

Diarrhoea  

19,339 

5,248 

12,115 

1,9848 

Dysentery  

6,105 

1,252 

2,792 

2,0619 

Cholera  

12,258 

3,049 

3,196 

6,013 

Scurvy  

23,365 

4,550 

17,576 

63910 

Diiferent  fevers  

42,453 

6,902 

34,420 

1,731 

Venereal  

1,455 

1,201 

241 

13" 

Skin  affections,  itch  

1,255 

1,128 

124 

312 

Total  

193,178 

50,106 

114,668 

28,404 

1  Many  died  of  typhus  and  cholera.  2  Complicated  with  typhus. 
3  Complicated  with  cholera,  typhus,  and  scurvy.  4  By  complication. 
6  Frequent  complication  with  typhus.  6  Cholera  and  typhus  compli- 
cations. 7  Many  cases  of  typhus.  8  Cholera  and  scurvy  complica- 
tions. 9  Ditto.  10  Typhus  complications.  u  By  complication. 
12  Ditto. 


APPENDIX. 


369 


Cholera  prevailed  most  in  June,  1855,  and  least  in  March  of 
the  same  year.  In  the  former  month  5466  cases,  and  2733  deaths, 
appear,  and  in  the  latter  only  3  cases,  and  1  death.  It  was  never, 
however,  totally  absent  up  to  the  end  of  1855,  when  the  return 
closes. 

Typhus  yielded  711  cases,  and  329  deaths,  in  an  effective  force 
of  90,000,  during  the  first  winter,  and  10,413  cases,  and  5689 
deaths,  in  a  total  force  of  140,000  men.  during  the  second  winter. 

Scurvy  was  at  its  maximum  in  February,  1856.  In  January, 
July,  August,  September,  and  December,  1855,  it  was  also  very 
prevalent,  but  by  June,  1856,  it  had  greatly  diminished.  In 
February,  1856,  4341  cases,  and  156  deaths  from  scurvy,  appear 
in  the  returns. 

Remittent  fever  prevailed  most  in  August,  1855,  and  least  in 
June,  1856.  Frost-bite  gave  3520  cases  to  the  hospitals,  followed 
by  28  deaths,  during  the  first  winter,  and  2076  cases  and  84  deaths 
during  the  second. 

Table  of  wounds. 


Rank. 

Treated 
in  the 
ambu- 
lances. 

Dis- 

cli:ir-cil 
cured. 

Sfllt  to 

Constan- 
tinople. 

Died 
in  the 
Crimea 

Killed. 

Slight 

WOlllllb, 

treated 

with  their 
regiments 

Officers  

1  625 

740 

770 

115 

325' 

1 

Non  commissioned 
officers  and  sol- 
diers . 

35  912 

10  178 

92  121 

3613 

7109 

1  1500 
J 

Total  

37  537 

10  918 

22  891 

37°8 

7507 

Total  loss,  adding  the  wounded  who  did  not  enter  the  hospitals, 
and  deducting  3500  Russians,  43,044  men  killed  and  wounded. 

Sixteen  thousand  were  killed,  or  died  of  their  wounds,  or 
after  operation.  The  taking  of  the  city  cost  the  French  5000 
wounded,  besides  the  many  killed.  In  twenty-two  months  114,668 
sick  or  wounded  were  transferred  from  the  Crimean  to  the  Con- 
stantinople hospitals.  The  average  was  5733  a  month  and  190  a 
day,  but  in  August  and  June  it  rose  to  350  a  day,  and  in  the 


3TO 


SURGERY   OP   THE    CRIMEAN    WAR. 


latter  month  a  total  of  10,600  were  thus  dispatched  to  the  Bos- 
phorus.  The  proportion  of  very  serious  wounds,  as  compared 
with  merely  severe  or  slight  injuries,  averaged  1  in  2T4ff.  Nearly 
the  half  had  their  lives  placed  in  jeopardy  by  their  wounds  re- 
ceived in  the  trenches;  1  in  5  died  on  the  place  of  combat,  and 
the  same  proportion  was  presented  at  the  battles  of  the  Alma, 
Inkerman,  and  Traktir.  The  average  gravity  in  these  latter 
affairs  was  1  in  4.  Finally,  primary  amputation  was  performed 
in  the  proportion  of  2  in  12  wounded. 


TABLE  showing  the  degree  of  gravity  from  wounds  and  the  accidents  of  tlie 
field,  and  the  general  number  of  deaths. 


Degree  of  gravity. 

Total 
cases. 

Propor- 
tion. 

Total  deaths 
in  the 
Crimea  and 
Constanti- 
nople. 

Propor- 
tion. 

Very  severe  —  fatal  on  the 
field     

7,507 

1  in  5-7 

7,507 

1  in    1-5 

Do.  calling,  or  not.  for  the 
removal  of  a  limb  
Medium  severity  

13,936 
8,817 

1  in  3-1 
1  in  5-1 

5,513 
2  300 

1  in    2 
1  in    3-3 

Slight  

13,284 

1  in  3-3 

1,000 

1  in  13  3 

Total  

43,044 

>. 

16,320 

APPENDIX. 


TABLE  showing  the  number  of  amputations  and  resections  performed  in 
the  Crimea,  and  their  results. 


Part. 

No.  of 

(•;i-cs. 

Proportion  of 
each  kind 
to  general 
total. 

Died  in  the 
Crimea. 

Transferred  to 
Constantinople, 
or  cured. 

No. 

Average. 

No. 

Average. 

Hip 

12 
1612 

58 
915 
241 
220 
168 
912 

278 
282 

100 
4098 

1  in  397 
1  in      3-1 
1  iu    80-5 
1  in      51 
1  in     19-6 
lin    21 
1  in     2S-2 
1  in      5-1 

1  in    17 
1  in    17 

1  in    41-6 

1275 

1  in  3-7 

3423 
3423 

1  in  1-3 

Thiirh 

Knee 

Lejr  .  .. 

Foot  

Toes 

Shoulder 

Arm 

Elbow,     forearm, 
or  wrist  

ll.ind  and  fingers. 
Lower  jaw  (resec- 
tion   and     tre- 
phine 

Totals  

1275 

The  following  shows  the  proportion  which  wounds  of  different 
regions  of  the  body  bore  to  one  another: — 

Head 1  wound  in    3-4 

Neck 1         «         40 

Thorax 1         "         12 

Abdomen 1         "         15 

Sup.  extrem 1         "  6'2 

Infer.      "     1         "  4-3 

These  figures  confirm  the  observations  made  in  the  body  of  the 
book  on  the  frequency  of  wounds  of  the  head  and  thorax  in  siege 
operations.  The  following  is  the  order  of  frequency  of  these 
wounds  received  in  an  open  engagement : — 

Head 1  wound  in  10 

Neck 1         "         12 

Thorax 1         "         20 

Abdomen 1        "        40 

Sup.  extrem 1          "  4-3 

Infer.      "     ,  ...1         »  3-6 


372 


SURGERY    OF   THE    CRIMEAN    WAR. 


TABLE  showing  the  wounds  and  diseases  treated  in  the  hospitals  at  Con- 
stantinople during  the  war. 


Transferred 
from  Varna 
or  the 
Crimea. 

Admis- 
sions at 
Constanti- 
nople. 

Dismissed 
cured 
or  well. 

Trans- 
ferred. 

Died. 

Wounds  (ordinary) 
"       by  gunshot 
Fro^t-bit  e 

2,185 
22,891 
3,472 
3,840 
3,196 
17,576 
63,124 
241 

124 

1,007 

142 

4,889 
2,570 
3,851 

8,038 
2,597 

156 

2,059 
9,616 
2,009 
3,544 
2,529 
9,587 
35,6-25 
2,316 

256 

720 
8,190 

775 
1,778 
1,076 
8,460 
22,988 
522 

24 

413 
5,085 
830 
3,407 
2,161 
3,380 
12,549 

Typhus 

Cholera  

Scurvy 

Fever 

Venereal 

Skin    affections 
fitch} 

16,649 

23,250 

6-7,541 

44,533 

27,825 

139,899 

139,899 

To  these  add  the  12,000  or  13,000  who  died  at  Varna,  Gallipoli, 
etc.,  and  the  total  loss  by  death  is  found  to  be  63,000,  viz. :  in  the 
Crimea,  28,404 ;  Gallipoli,  Yarna,  Piraeus,  etc.,  5500 ;  Constanti- 
nople, 27,823;  in  the  Turkish  hospitals,  12,000  to  13,000. 

The  French  had  in  Turkey  fifteen  hospitals,  containing  in  all 
10,850  to  11, 850  beds. 

M.  Scrive  shows  most  conclusively  how  much  more  severe  the 
duty  was,  which,  toward  the  end  of  the  siege,  devolved  on  the 
French,  as  compared  with  the  English  army.  He  gives  ample 
proof  of  the  good  effects  of  chloroform,  and  states  that  no  dis- 
agreeable results  whatever  arose  in  their  army  from  its  use,  and 
he  gives  his  entire  adhesion  to  the  necessity  for  early  amputation 
in  all  cases  except  those  at  the  hip-joint,  when  he  thinks  delayed 
operations  do  best.  M.  Scrive's  volume  contains  much  interest- 
ing and  valuable  information,  chiefly  on  the  diseases  which  com- 
mitted such  ravages  among  the  French  troops  in  the  Crimea. 

APPENDIX  I. 

Since  the  foregoing  pages  were  printed,  the  Government  Re- 
port on  the  Medical  History  of  the  War  has  appeared.  The 
following  resum^  is  added,  along  with  the  Surgical  Statistics,  not 
given  in  the  text. 


APPENDIX. 


373 


The  medical  part  of  the  report  not  having  as  yet  been  issued, 
no  extracts  are  given  from  it.  However,  such  medical  statistics 
as  are  required  to  elucidate  the  surgery  of  the  war  have  been 
obtained  through  the  kindness  of  the  Director-General,  and  have 
been  given  in  the  body  of  the  book. 

It  may  be  here  remarked,  that  the  following  numbers  refer  to 
the  period  after  April  1st,  1855,  so  far  as  the  men  are  concerned, 
and  to  the  whole  war  for  the  officers,  except  when  otherwise 
stated. 

The  total  number  killed  in  action  during  the  whole  war 
amounted  to  2598  men,  157  officers,  or  2-7  per  cent,  of  the  total 
force  of  men  sent  out,  and  4-0  per  cent,  of  the  total  strength  of 
officers. 

The  proportion  of  the  various  classes  of  wounds  to  each  other, 
and  to  the  whole  number  of  wounded  per  cent.,  and  the  mortality 
by  each  per  cent,  of  cases  treated  among  the  officers  for  the  entire 
war,  and  the  men  for  the  second  period,  is  shown  in  the  following 
table :— 


Proportion  per 
cent,  of 

total  NV.niiulfil. 

Mortality  per 
cent,  of 
cases  treated. 

In 

men. 

In 
officers. 

In 
item. 

In 

officers. 

Gunshot  wounds  of  the  head  

11-9 
7-4 
1-7 
58 
3-2 

0-7 
4-5 
30-2 
31-7 
0-1 
0-5 
1-7 

8-1 
6-9 
3-2 
9-3 

5-7 

0-7 
5-0 
19-0 
35-5 
0-5 
1-7 
3-8 

20-0 
2-6 
3-1 
28-1 
55-7 

30-9 
13-8 
2-9 
83 

li'i 

4-7 

17-0 

ID'S 

31-5 

51-5 

10-3 
3-6 
7-2 

4-5 

face  

neck  

chest 

abdomen 

perineum    and 
genitals  

back  and  spine., 
upper  extremity 
lower  extremity 
Sword  and  lance  wounds  

Bayonet  wounds  

Miscellaneous  wounds  and  injuries  

Of  the  above  injuries,  the  following  pro- 
portion required  amputation  or  resection. 

108 

7-7 

27-8 

33  3 

32 


374 


SURGERY    OF   THE    CRIMEAN    WAR. 


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APPENDIX. 


375 


No.  1. — Return  of  wounds  and  injuries  received  in  action,  admitted  for 
treatment  in  the  hospitals  in  the  Crimea,  from  the  first  landing  at  Old 
Fort  to  the.  end  of  March,  1855.  {Non-commissioned  officers  and  pri- 
vates onh/.) 


£ 

L 

o  a 

Is 

H  ** 

2 

<S3 
$ 

.£"3 

P 

Discharged  to  duty 
from  the  field  hos- 
pitals. 

Discharged  to  be 

readmitted  under 
the  head  amputa- 
tion or  excision. 

1 

h 

Remained  under 
treatment  on  31st 
March,  1855. 

Gunshot  wounds  of  the  head. 
'•        face  

206 

!:>.•> 

25 

94 
54 

... 

84 
66 

3 

5 

"             '*        neck 

64 

1 

14 

44 

5 

"             "        chest  
"             "        abdomen. 
"        perineum 
and  genito-  urinary  organs. 
Gunshot  wounds  of  the  back 
and  spine 

153 
100 

15 

84 

32 
36 

4 
13 

14 

8 

20 

... 

104 
63 

11 
49 

3 
3 

2 

Gunshot  wounds  of  the  ex- 
tremities   

1763 

38 

251 

252 

1176 

46 

Sword  and  lance  wounds  
Bayonet  wounds  

77 
30 

3 

22 
2 

55 
20 

5 

Miscellaneous  wounds  and  in- 
juries .  . 

2 

1 

1 

Particulars    not    known,    no 
records-  of    them    having 
been  kept,  or  the  records 
having  been  lost  

1815 

132 

46 

4 

1633 

Total  wounds  

4434 

284 

5"(i 

250 

:r»!)<; 

72 

From   the   above   cases,   256 
primary   amputations   and 
resections     are     returned, 
which  were  thus  disposed 
of  

22 

6* 

220 

g 

4434 

306 

532 

... 

3516 

80 

*  Of  portions  of  fin^.-rs. 


316 


SURGERY   OF   THE   CRIMEAN    WAR. 


No.  2. — Shoiving  the  final  result  of  4434  wounds  received  during  the 
above  period. 


d  from 
nea  for 
eatment. 

:Sl 

lf| 

N 

ti 
*f| 

1 
S 

H* 

if 

"E2"** 

J 

.£«£ 

Ill 

IH 

*|1 

.si 
*>> 

|il 

Gunshot  wounds......  "1 

68 

3001 

332 

1234 

1435 

Sword,  lance,  and  bayonet  j 
wounds           1- 

3296 

146 

5 

129 

12 

Gunshot     contusions     and  j 
miscellaneous  wounds....  J 
Primary  amputations 

216 

14 

81 
202 

10 
41 

35 

36 
161 

Primary  resections          . 

4 

4 

1 

3 

Final  result  of  4434  wounds.. 

3516 

82 

3434 

389 

1398 

1647 

"It  will  be  seen  by  return  No.  1  that  the  particulars  of  1815 
cases  are  not  reported.  Either  they  were  not  recorded,  or  in  the 
confusion  of  the  battles  of  Alma,  Balaklava,  or  Inkerman,  the 
records  descriptive  of  the  nature  of  the  wounds  received  were 
lost,  and  all  that  can  now  be  determined  is,  that  the  above  num- 
bers were  wounded,  and  died  of  their  wounds  before  arrival  at  the 
secondary  hospitals  on  the  Bosphorus. 

"  It  is  also  to  be  regretted  that  the  form  of  return  adopted  at 
Scutari,  during  this  period,  does  not  admit  the  results  of  the  vari- 
ous wounds  to  be  shown  by  regions,  as  in  return  No.  1.  This  is, 
however,  the  less  of  moment  for  statistical  purposes,  as  the  par- 
ticulars of  so  large  a  number  as  1815,  or  nearly  one-third  of  the 
total,  being  unknown,  would  render  any  numerical  inferences 
drawn  from  this  series  of  wounds  very  imperfect.  To  the  series 
of  the  second  period,  or  that  following  March,  1855,  this  remark 
is  not  applicable,  as  the  returns  were  kept  with  the  greatest  care, 
and  it  is  believed  the  results  may  be  implicitly  relied  on." 


APPENDIX. 


377 


No.  3 — Return  of  Wounds  find  Injuries  received  in  action.  (Non-com- 
mixsioned  officers  and  private*  only.)  Showing  the  numbers  and  results 
of  cases  treated  from  the  1st  of  April,  1805,  to  the  end  of  the  war. 


Total  1  1 

j, 

'3 

•o 

2 

|l| 

1 
o 

ll 

Gunshot  wounds  of  the  head 

851 

179 

MM 

87 

face 

533 

14 

446 

74 

neck 

1V8 

4 

108 

16 

chest 

420 

118 

226 

76 

abdomen  
perineum  and 
genito-urinary  organs   

286 

55 

131 

17 

71 



33 
16 

(iunshot  wounds  of  the  back  and  spine 

826 

46 

226 

4i               <•      extremities  
Sword  and  lance  wounds  

I486 

7 

254 

1 

2  .")!'»; 
5 

766 


890 
1 

I'.'iyniict  wound-; 

4 

.,., 

10 

M  i^rollaneous  wounds  and  injuries 

126 

6 

26 

Total  of  wounds  treated.  (72  of  which 
remained  on  March  31    1855  ) 

7153 

704 

1  :',:','• 

766 

1284 

From    the    above   cases  700  amputa- 
tions and  resections  resulted,  5  of 
which    required    further  operation. 
:ind  s  cases  of  amputation  remained 
on  31st  of  March.    Total,  770,  which 
were  thus  disposed  of 

*?7 

6 

530 

Add  the  H  amputations  remaining  on 
31st  March  

8 

Fin.il  result  of  the  total  number  treated 
during  the  above  period 

7161 

981 

4366 

771 

1814 

*  Of  portions  of  fingers. 

The  foregoing  and  following  returns  include  gunshot  and  other 
injuries  analogous  to  those  received  in  action,  such  as  wounds  by 
the  accidental  discharge  of  fire-arms,  and  injuries  received  at  the 
great  explosion  of  reserve  ammunition  on  the  15th  November, 
1855.  Of  the  total  number  of  men  "invalided  or  transferred,'* 

32* 


378 


SURGERY    OF    THE    CRIMEAN    WAR. 


viz.,  1814,  only  1671  were  invalided  to  England ;  the  ramainder 
went  to  duty  from  Scutari.  A  large  proportion  of  officers  "  in- 
valided," returned  to  duty  subsequently  to  their  arrival  in  Eng- 
land. 

No.  6. — Return  of  Wounds  and  Injuries  received  in  action  (Commis- 
sioned officers  only.}  Showing  the  number  and  results  of  cases  treated 
from  commencement  to  the  end  of  the  war. 


1 
I 

I 

Discharged  to  duty. 

Discharged  to  be  re- 
admitted under  the 
head  amputation  or 
excision. 

Invalided. 

47 

8 

?9 

10 

face  

neck 

40 
19 

9 

29 
8 



11 

9 

chest 

54 

17 

1° 

25 

abdomen  

88 

17 

9 

7 

perineum  and 
genito-urinary  organs  

4 

1 

3 

Gunshot  wounds  of  the  back  and  spine. 

29 

s 

18 

s 

"               "      extremities  
Sword  and  lance  wounds 

318 
3 

19 

122 
3 

45 

132 

Bayonet  wounds 

10 

7 

3 

Miscellaneous  wounds  and  injuries 

^2 

1 

4 

17 

Total  of  wounds  treated 

579 

67 

242 

45 

225 

From  the  above  cases  45   operations 
resulted,  which  were  thus  disposed 
of  . 

15 

30 

Final  result  of  total  number  treated 

579 

82 

242 

255 

The  general  result,  then,  is  that — 

1.  Of  wounded  non-commissioned  officers  and  privates  received 
for  treatment  during  the  first  period,  viz.,  4434,  777  died,  or  17'5 
per  cent.;  1930  returned  to  duty,  or  43-5  per  cent.;  1647  were 
invalided  to  England,  or  37-1  per  cent.;  and  80  remained  under 
treatment  in  the  Crimea  on  31st  of  March,  1855,  carried  into  the 
second  period. 


APPENDIX.  379 

2.  Of  wounded  non-commissioned  officers  and  privates  received 
for  treatment  during  the  second  period,  viz.,  7081,  (and  80  re- 
mained under  treatment  in  the  Crimea  on  3lst  March,  1855-^- 
total  7161,)  981  died,  or  13-7  per  cent.;  4509  returned  to  duty,  or 
63-0  per  cent.;  1671  were  invalided  to  England,  or  23-3  per  cent. 

3.  Of  wounded   officers   treated  during  the  entire  war,  viz., 
579,  82  died,  or  14-1  per  cent.;  242  returned  to  duty,  or  41'7  per 
cent.;  255  were  invalided  to  England,  or  44  per  cent. 

Making  a  grand  total  of  12,01)4  wounded  officers  and  men 
treated,  (exclusive  of  2755  killed  in  action,  as  given  in  returns 
furnished  by  the  adjutant-general,)  of  whom  1840  died,  6681  re- 
turned to  duty,  and  3573  were  invalided  home. 

GUNSHOT    WOUNDS    OF    THE    HEAD. 

Besides  the  numbers  given  in  chapter  vii.,  and  which  refer  to 
the  men  only,  the  following  cases  occurred  among  officers  during 
the  whole  war.  Contusions,  more  or  less  severe,  38,  with  no 
deaths;  contusion  or  fracture,  but  no  apparent  depression,  2,  with 
1  death;  same,  with  depression,  2,  and  2  deaths;  5  penetrating 
wounds,  and  5  deaths. 

The  remarks  made  in  the  body  of  the  book,  on  the  management 
of  these  cases,  are  fully  confirmed  by  the  writer  of  the  report. 
He  states,  moreover,  that  "symptoms  of  compression  from  abscess 
of  the  brain"  usually  came  on  from  the  fifteenth  to  the  30th  day. 
A  form  of  injury  is  also  spoken  of  in  the  report  which  I  have 
never  seen,  viz.,  the  cavity  of  the  skull  being  opened  by  the 
knocking  off  of  the  mastoid  process. 

In  23  cases  an  operation  for  the  removal  or  elevation  of  de- 
pressed bone  was  performed,  and  7  recovered.  The  following 
gives  some  of  the  leading  points  of  interest  connected  with 
them : — 

1.  Three  slight  lacerated  wounds  on  the  left  side  of  the  head; 
insensibility  for  some  time  after  injury,  but  apparent  recovery — 
with  headache  and  febrile  symptoms  for  a  day  or  two.  Symp- 
toms set  in  a  month  afterward,  (intermediate  treatment  not  given ;) 
violent  pain  in  his  head,  drowsiness  and  stupidity,  distortion  of 
face,  febrile  symptoms,  puffy  swelling  at  wounds.  Incision  showed 
separation  of  pericranium;  depression  overcome  by  Key's  saw 
and  elevator;  dura  mater  inflamed,  but  untorn.  Symptoms  re- 
lieved, but  hernia  appeared.  Final  recovery. 


X 

380          SURGERY  OF  THE  CRIMEAN  WAR. 

2.  Lacerated  wound  over  right  parietal,  and  comminuted  frac- 
ture, with  considerable  depression.      Headache,  but  no  febrile 
symptoms.     Ten  days  after  injury,  cord-like  pain  in  the  head,  and 
hearing  affected.    Leeches,  and  general  bleeding  to  twenty  ounces, 
without  relief.     Delirium.     Eight  pupil  dilated.     Pulse  100,  and 
hard.     Skin  hot  and  dry.     Trephined  on  the  eleventh  day.     Ex- 
ternal and  internal  tables  separated,  and  a  piece,  of  wood  im- 
pacted in  the  fracture  and  resting  on  dura  mater.     Two  circles 
removed  by  trephine,  and  more  bone  by  Hey's  saw,  to  permit  of 
rectifying  the  injury.     Dura  mater  uninjured.     Immediate  relief 
and  final  recovery. 

3.  Fissured  fracture,  with  slight  depression,  by  ghell  wound. 
On  the  fifth  day,  slight  symptoms  of  compression,  with  febrile 
state.     On  exposing  the  bone,  some  of  the  hair  was  found  fixed 
in  the  fracture.     Depressed  bone  removed  by  trephine.    Inner 
table  more  injured  than  external,  part  being  detached.    Blood  on 
dura  mater,  which  was  entire.     Recovery. 

4.  Primary  operation.     Recovery. 

5.  Compound  fracture  of  squamous  portion  of  left  temporal. 
Bleeding  from  the  ear.     Four  large  pieces  of  bone  removed,  and 
another  elevated.     Dura  mater  entire.     From  being  insensible  on 
admission,  he  slowly  recovered  during  the  following  days.     Deaf- 
ness complete  on  left  side,  and  partial  on  right.    Suppuration  from 
the  ear.     Had  headache,  and  a  stupid,  vacant  expression  of  face 
when  sent  to  England. 

6.  Operation  three  days  after  injury.     Recovery. 

7.  Keefe,  whose  case  is  fully  given  at  page  192. 

These  were  the  7  successful  cases  of  interference.     The  follow- 
ing were  fatal : — 

1.  Fracture  of  the  right  parietal.     No  sypiptoms  for  thirteen 
days.     Rigors  and  drowsiness  then  set  in,  high  pulse,  pain  in 
head,  and  intolerance  of  light;   20  leeches  applied.     Purgative 
and  calomel  (gr.  ij)  every  two  hours.     Convulsive  spasms,  and 
finally  paralysis  of  arm  and  dilatation  of  pupils.     Operation  on 
the  14th  day.      Inner  table  fractured  and  depressed.     Clot  on 
dura  mater,  which  was  entire.     Slight  relief  at  first,  but  ultimate 
death  on  the  twenty  second  day.     Abscess  found  in  right  hemi- 
sphere, find  fungus  growth  on  surface  of  the  dura  mater. 

2.  Depressed   fracture   of    posterior  part   of    right  parietal. 
Three  days  afterward  dilatation  of  right  pupil,  and  headache, 


APPENDIX.  381 

double  vision,  fever,  etc.  Had  leeches  to  temples,  and  been  bled 
previously.  Trephine  applied.  Small  part  of  dura  mater  sloughy, 
and  covered  with  lymph.  Small  qmmtity  of  pus  between  dura 
mater  and  bone.  Considerable  bleeding  from  vessels  of  scalp. 
Calomel  (gr.  ij)  every  three  hours,  and  antimonials  every  two 
hours.  A  week  after  operation  worse,  and  bleeding  to  thirty 
ounces  ordered,  with  calomel  and  antimony  repeatedly.  Jaundice 
before  death  by  coma,  on  the  eleventh  day  from  operation,  and 
sixteenth  from  injury.  Membranes  of  brain  found  inflamed,  and 
abscess  in  the  posterior  lobe  extending  to  place  of  injury. 

3.  Compound  depressed  fracture  of  the  left   temporal  bone. 
Some  loose  fragments  removed  four  days  afterward.    On  the  four- 
teenth  day,  jaundice  and  delirium,  and   seven   days  afterward 
death.     Treatment  not  stated.     "  A  piece  of  the  internal  table 
was  found  in  the  cavity  of  an  abscess,  the  size  of  a  walnut,  at 
the  seat  of  injury." 

4.  Bone,  to  a  small  extent,  denuded  by  a  shell  wound.     Mem- 
ory impaired  on  the  sixteenth  day;  he  was  also  stupid;  had,  in 
succession,  pain  in  the  head,  dilated  pupils,  and  rigors.     On  in- 
cision of  the  scalp  only  a  very  small  scale  of  bone  was  found 
loose,  and  was  removed.     Next  day  pus  and  air  escaped  at  each 
beat  of  the  heart  by  the  parieto-frontal  suture,  which  had  been 
laid  bare  by  the  explorative  incision.    Head  symptoms  increased. 
Trephined.     Part  of  inner  table  found  depressed  and  detached. 
Dura  mater  inflamed,  but  entire.     Two  days  after,  jaundice  and 
fever,  and  death  on  seventh  day  from  operation,  and  twenty-fourth 
from  injury.     Large  abscess  found  in  center  of  right  hemisphere, 
communicating  with  the  wound,  and  the  surface  of  the  hemisphere 
was  coated  with  pus. 

5.  Compound  comminuted  and  depressed  fracture  of  anterior 
inferior  angle  of  right  parietal  bone  by  shell.     Headache  alone 
for  three  days.     Journey  from  camp  to  Castle  hospital  exhausted 
him  much.     On  fourth   day  (next  after  journey)  symptoms  of 
compression.     Trephined,  and  much  bone,  which  was  depressed 
and  broken,  removed.     Dura  mater  lacerated,  and  lymph  effused 
on  the  brain.     Sensibility  returned  when  the  bone  was  elevated, 
and  he  improved  much.     For  two  days  only  headache  and  intol- 
erance of  light.     Jle  then  felt  as  if  "something  gave  way  in  his 
head,"  and  a  hernia  appeared.     He  got  worse,  and  finally  sank 
comatose,  on  the  fifth  day  after  operation,  and  ninth  from  injury. 


382  SURGERY   OF    THE   CRIMEAN    WAR. 

Dura  mater  found  lacerated  and  sloughy;  brain  below  place  of 
injury  softened,  arid  a  large  abscess  in  the  right  anterior  lobe  of 
the  brain.  Pus  over  whole  external  surface  of  right  hemisphere. 

6.  Depressed  fracture  of  the  middle  of  the  frontal  bone  by 
shell.     Headache  and  constitutional  disturbance.     Trephined  on 
the  sixth  day,  and  depressed  and  detached  bone  elevated.     Dura 
mater  slightly  lacerated.     Lost  power  of  utterance  twelve  days 
after  operation,  and,  notwithstanding  active  treatment,  got  rap- 
idly worse.    Convulsions,  paralysis  of  the  sphincters  and  bladder, 
coma  and  death  on  the  sixteenth  day  from  operation,  and  twenty- 
second  from  injury.     Previous  to  death  a  trocar  was  inserted,  to 
the  depth  of  an  inch,  into  the  brain,  in  the  disappointed  hope  of 
evacuating  pus.     Lymph  was  found  deposited  in  the  arachnoid, 
and  much  serum  in  the  ventricles.     "It  seems  worth  noting  that 
the  symptoms  in  this  case,  which  seemed  to  have  resulted  from  a 
nearly  pure  attack  of  arachnitis,  are  almost,  if  not  quite,  identi- 
cal with  those  observed  in  many  cases  where  abscess  of  the  brain 
was  the  main  post-mortem  lesion  found." 

7.  Shell  wound,  denuding  small  part  of  frontal  bone.     Very 
little  complaint  for  a  month,  when  he  was  seized  with  headache, 
vertigo,  and  intolerance  of  light.    Pupils  and  pulse  little  affected. 
Treatment  for  a  fortnight  by  calomel,  purgatives,  tartar  emetic, 
and  low  diet.     No  bleeding.     He   got  worse  —  became   almost 
idiotic.    On  the  fifty-third  day  from  injury,  and  the  twenty-fourth 
from  the  setting  in  of  bad  symptoms,  an  exploration  was  made,' 
which  discovered  a  piece  of  the  outer  table  loose,  and  on  this 
being  removed   the  inner  table  was  seen  to  be   fractured  and 
depressed.     Two  inches  of  bone  were  removed  by  the  trephine. 
A  small  fragment  was  found  driven  through  the  dura  mater. 
This  was  removed.     Calomel  was  given  freely.     Eepeated  large 
bleedings.     Got  better  for  a  day,  and  ultimately  grew  worse,  and 
death  relieved  him  eighty-eight  days  from  the  time  of  injury,  and 
four  days  after  the  application  of  the  trephine.    Lymph  found  on 
the  surface  of  the  dura  mater  at  the  seat  of  injury.     A  sharp 
piece  of  bone  was  found  impacted  in  the  brain,  and  from  it,  nearly 
to  the  base  of  the  anterior  lobe,  an  elongated  abscess,  distinctly 
circumscribed,  was  found  filled  with  sanio-purulent  fluid.     Pus 
over  the  surface  of  the  right  hemisphere,  and  clotted  blood  near 
the  wound.     The  arachnoid  was  inflamed.     The  inner  table  fis- 
sured beyond  what  was  removed,  and  new  bone  was  plentifully 
deposited  at  the  seat  of  fracture. 


APPENDIX.  383 

8.  Ball  partially  impacted  a  little  above  and  behind  the  right 
ear.     No  urgent  symptoms,  except  headache,  for  twenty-three 
days,  when  he  was  sent  to  the  rear.      Next   day  after  journey 
headache  increased,  and  other  head  symptoms  followed.     Ball 
then  easily  removed,  but  as  the  hemorrhage  which  succeeded 
caused  much  faintness,  deeply  depressed  portions  of  bone  were 
not  interfered  with.     Relief  followed  the  immediate  removal  of 
the  ball,  but  his  symptoms  having  progressed,  the  trephine  was 
applied  next  days     The  dura  mater  was  extensively  lacerated. 
Improvement  for  two  days,  and  then  hernia  cerebri,  and  profuse 
purulent  discharge.    Hernia  treated  by  slicing,  caustic,  and  pres- 
sure.    Flow  of  pus  suddenly  ceased,  and  fungus  rapidly  increased 
by  the  twenty-fifth  day  after  the  operation.      Became  rapidly 
comatose.     By  means  of  a  grooved  director  much  pus  was  evac- 
uated during  the  next  two  days,  and  he  again  became  sensible. 
He  continued  so  for  three  days,  the  hernial  protrusion  having,  in 
the  mean  time,  sloughed   away.      He  again  became  comatose, 
notwithstanding  the  free  escape  of  pus.  and  lie  died  two  months 
after  the  receipt  of  the  wound,  and  thirty-four  days  after  the 
operation.    Nearly  the  whole  right  hemisphere,  as  far  as  the  ven- 
tricle, was  found  converted  into  an  abscess  with  a  distinct  lining. 
Pus  was  found  in  the  other  ventricles,  and  lymph  abundantly 
effused   at   the   base   and   other  parts.     Another   and   distinct 
abscess  was  found  at  the  base  of  the  middle  lobe  of  the  left 
hemisphere. 

9.  Depressed  fracture  of  occipital  bone,  with  round  ball  im- 
pacted, which  was  removed  by  the  trephine  three  days  after  its 
introduction.    The  withdrawal  of  a  small  spiculum  of  bone,  which 
had  penetrated  the  torcular  herophili,  was  followed  by  easily- 
arrested  venous  hemorrhage.     The  dura  mater  was  intact.     He 
had  no  bad  symptoms  for  twelve  days,  when  he  was  seized  with 
what  appeared  to  be  congestion  of  the  lungs,  and  died  in  a  week, 
the  wound  being  then  nearly  healed.     Nothing  except  signs  of 
recovery  were  found  in  the  head. 

10.  Round  ball  lodged  deep  in  temporal  muscle,  with  extensive 
fracture  of  the  bone.     No  symptoms  except  headache  for  three 
<l;i\s,  when  signs  of  compression  appeared.      By  the  trephine 
twelve  fragments  of  bone  and  a  clot  of  blood  were  removed,  but 
he  never  rallied,  and  died  in  thirty-six  hours.     The   treatment 
from  the  first  had  been  strictly  antiphlogistic ;  but  this  patient 


384  SURGERY    OF    THE   CRIMEAN    WAR. 

was  a  very  bad  subject,  being  plethoric  and  intemperate.     No 
post-mortem. 

11.  Depressed  fracture  of  right  temporal  and  parietal  bones, 
followed  by  well-marked  signs  of  compression.    Trephined.    Dura 
mater  torn,  and  a  slight  escape  of  cerebral  matter.     Became  im- 
mediately sensible,  and  went  on  improving  till  the  formation  of  a 
large  hernia   cerebri   took   place.     Forty-one  days  after  injury 
headache  and  stupor  set  in,  followed  by  paralysis  of  the  left  side, 
and  death  fifty-three   days  after  wound   and  .operation.     Dura 
mater  found  adherent  all  round  the  wound,  and  pus  at  the  base 
and  in  the  right  ventricle. 

12.  Compound  depressed  fracture  of  the  skull.     No  symptoms 
for  a  fortnight,  then  those  of  compression.      Trephined.      No 
relief  to   symptoms.     Death.     Membranes   much  inflamed,  and 
effusion  of  blood  into  the  brain. 

13.  Fracture  with  depression.    Primary  operation.    No  relief; 
and  death,  comatose,  5  days  after  operation,  from  encephalic  in- 
flammation, softening  of  the  brain,  and  abscess. 

14.  Compound  depressed  fracture  of  the  frontal  bone.    Opera- 
tion demanded  by  symptoms  within  24  hours.     No  relief.     Death 
20  hours  after  operation.     Found  to  be  fracture  of  the  base,  with 
effusion. 

15.  Compound   depressed    fracture   of  occipital.      Operation, 
hernia,  and  death. 

16.  Compound    depressed   fracture    of    left    temporal    bone. 
Operation,  and  speedy  death. 

17.  Operation  on  appearance  of  symptoms  "some  days"  after 
injury.     Depressed    fracture    of    occipital.     No    relief.     Death. 
Fracture  extended  to  the  basilar  process,  and  "  one  edge  of  the 
internal  table  had  been  slightly  raised  along  the  whole  of  fissured 
fracture." 

18.  Extensive   depressed   fracture   by  shell.     Operation  with 
Hey's  saw.     Did  well  for  20  days,  then  signs  of  compression,  and 
death  from  abscess. 

19.  Another  similar  case,  only  living  two  days. 

It  is  to  be  regretted  that  the  treatment  pursued  during  the 
period  which  intervened  between  the  receipt  of  the  injury  and 
the  appearance  of  dangerous  symptoms  has  not  been  recorded  in 
the  interesting  notes  given  of  the  above  case.  The  following, 
then,  show  the  total  result  of  operative  interference  in  these 
cases : — 


APPENDIX.  385 

Cases      Recoveries      Recoveries          T  .  ,  Deaths          Deaths  T  .  , 

treated.      without  after         recoreriai       witlK>ut          aftl'r  deaths 

Total.      operation.        operation.     '  *    operation,     operation. 

76  14  7  21  36  19  55 

All  the  cases  which  had  undergone  operation  are  reported  from 
Chatham  to  suffer  still  from  vertigo  and  headache. 

There  were  discharged  from  Chatham,  88  men,  on  account  of 
disabilities  arising  from  head  injuries.  These  men  suffered  chiefly 
from  headache,  partial  paralysis,  mental  weakness,  or  affections  of 
the  special  senses. 

GUNSHOT    WOUNDS    OF    THE    FAi'K. 

"Five  hundred  and  thirty-three  cases  came  under  treatment 
among  the  men  during  the  second  period,  or  7-4  per  cent,  of  the 
entire  wounded.  Fourteen  of  the  patients  died,  or  2*6  per  cent, 
of  those  treated.  One  of  these  deaths  was  caused  by  tetanus, 
under  which  head  the  case  has  been  given,  the  eyeball  having 
been  destroyed  and  the  optic  nerve  injured ;  two  by  inflammation 
of  the  membranes  of  the  brain  supervening,  where  one  eye  had 
been  destroyed ;  and  two  by  the  same  cause,  where  no  injury  to 
this  organ  had  taken  place,  but  the  bones  of  the  face  had  been 
extensively  injured.  In  four,  very  extensive  and  dec}:  injury  and 
laceration  of  the  face,  including  the  tongue,  had  been  inflicted ; 
two  were  complicated  with  extensive  burns  from  explosion,  and 
in  the  remaining  three  the  cause  of  death  is  not  specially  reported. 
Among  the  officers  no  fatal  case  occurred." 

The  following  case  is  well  worthy  of  being  extracted  : — 
4<  Private  Robert  Cuthbert,  aged  19, 31st  Regiment,  was  wounded 
on  2d  September  by  a  grape-shot,  which  struck  him  in  the  face, 
badly  fracturing  the  lower  jaw.  On  removing  the  bandages  which 
had  been  placed  on  the  parts  in  the  trenches,  the  fractured  bone, 
with  its  muscles,  glands,  etc.,  fell  down  on  the  cheek,  dragging 
the  tongue  with  it,  and  exposing  the  interior  of  the  mouth  and 
throat  as  far  as  the  root  of  the  tongue,  and  the  wound  extended 
into  the  anterior  triangle  of  the  neck,  exposing  the  carotid  artery. 
The  bone  was  so  comminuted,  that  no  choice  was  left  but  to 
remove  the  fragments,  and  the  jagged  ends  of  the  bone  were  sawn 
even  on  each  side.  No  part  anterior  to  the  angles  of  the  bone 
could  be  saved:  the  soft  parts  were  then  brought  together,  and 
retained  by  sutures,  and  a  few  adhesive  strips  and  wet  lint  ap- 
plied. The  patient  was  now  able  to  lie  down,  which  he  could  not 

33 


386 


SURGERY   OF   THE   CRIMEAN    WAR. 


do  before,  as  the  tongue,  by  falling  back,  closed  the  glottis ;  but 
even  now,  when  in  the  recumbent  position,  he  had  frequently  to 
lay  hold  of  the  tongue,  and  draw  it  forward,  to  facilitate  breathing. 
A  considerable  portion  of  the  injured  integuments  of  the  chin 
sloughed  away,  but  by  careful  feeding,  dressing,  and  bandaging, 
the  deformity  was  ultimately  much  less  than  could  have  been  ex- 
pected. In  this  case,  of  course,  the  food  was  required  to  be  in 
the  liquid  or  semi-liquid  state,  and  for  a  long  time  great  difficulty 
was  experienced  in  feeding  him;  but  he  experienced  much  comfort 
from  the  use  of  a  small  pipe,  through  which  he  sucked  his  food. 
He  was  sent  to  England  on  24th  November,  well,  and  much  good 
might  have  been  expected  to  result  from  an  operation  in  remedy- 
ing a  portion  of  the  deformity,  as  soon  as  the  parts  were  suffi- 
ciently consolidated  to  warrant  such  a  proceeding." 

In  the  33d  Regiment,  the  external  carotid  was  successfully  tied 
for  primary  hemorrhage  from  it. 

In  one  case,  a  comrade's  double  tooth  was  found  imbedded  in 
a  patient's  eye ;  in  another,  tetanus  arose  from  injury  to  the  optic 
nerve  ;  and  in  a  third,  a  portion  of  another  man's  skull  was  removed 
from  between  the  lids  of  a  patient. 


GUNSHOT   WOUNDS    OF    THE    CHEST. 

Return  of  officers  during  the  entire  war. 


1 

Total  died. 

Discharged 
for  duty. 

Invalided  or 
transferred. 

1.   Simple  flesh  contusions  and  )  Slight  
wounds                       .     .   .  /Severe  

11 
14 

... 

7 
g 

4 
9 

2.  With  injury  of  bone  or  cartilage,  but  without 
known  lesion  of  the  contents,  and  not  open- 

6 

1 

6 

3.  With  lesion  of  the  contents,  but  not  opening 

1 

1 

4.   Penetrating  the  cavity,  and  missile  lodged,  or 

8 

7 

1 

5    Perforating   or  apparently  )  Superficially  .  .  . 

1 

1 

perforating  the  cavity     j  Deeply        .    . 

18 

8 

6 

Total                                             .    ..  . 

54 

17 

12 

flft 

APPENDIX. 


387 


"  Of  these  wounds,  420  have  been  treated  among  the  men, 
being  5-8  per  cent,  of  the  entire  wounded  during  the  period.  Of 
these  men,  109  died  in  the  primary  hospitals ;  8  in  the  secondary 
hospitals  ;  and  1  of  intercurrent  disease,  (idiopathic  fever,) — mak- 
ing a  total  of  118  deaths,  or  28  per  cent,  of  the  cases  treated.  The 
very  large,  proportion  of  the  deaths  in  the  primary  hospitals  is 
remarkable,  and  arose  from  the  great  seventy  of  the  injuries 
received,  by  which  death  was  in  very  many  instances  caused 
within  a  few  hours,  and  in  this  and  the  following  class  especially 
an  unusually  large  proportion  of  these  fatal  cases,  under  more 
ordinary  circumstances,  would  have  been  mortnl  on  the  field,  and 
therefore  only  admitted  on  the  returns  as  '  killed  in  action.' 
From  the  proximity  of  the  trenches,  however,  they  were  rapidly 
transferred  to  the  hospitals,  where,  although  the  care  and  skill  of 
the  surgeon  might  perhaps  prolong  life  for  a  few  hours,  it  was 
but  too  evident  that  many  were  hopeless  from  the  commencement. 

"Among  the  officers  54  cases  occurred,  or  very  nearly  10  per 
cent,  of  the  whole  wounded,  of  which  number  17  were  fatal,  being 
31*6  per  cent,  of  the  cases  treated,  a  proportion  in  both  instances 
considerably  over  that  among  the  men." 

In  one  case  of  contusion  of  the  walls  of  the  chest,  an  abscess 
formed  between  the  pleura  and  the  parietes. 

GUNSHOT    WOUNDS    OF    THK    ABDOMEN. 

Return  showing  the  nature  and  results  of  cases  treated  from  the  commence- 
ment to  the  end  of  the  war.     (Commissioned  officers  only.) 


1 

I 

o 

1 

i 

r.   >-. 

1 

3 

II 

i 

H 

H 

0 

1-1 

1.  Simple  flesh  contusions  and  "1  Slight  

8 
6 

.... 

8 
1 

H 

2  and  3.   Penetrating,  or  appar-    f"  Nature  not  ^ 

ently  penetrating  or   per-  J    accurately  > 

2 

1 

.... 

i 

forating    the    cavity,    with  1     known  J 

lesion  [  Of  viscera  

16 

14 

i 

5.  Fracture  of  the  pelvis,  not  being  at  the  same 

time  wounds  opening  the  cavity  of  ihe  ab- 

domen   

2 

2 

Total  

88 

17 

9 

7 

388  SURGERY   OP    THE    CRIMEAN    WAR. 

"  For  these  injuries,  including  gunshot  fractures  of  the  pelvic 
bones,  there  were  treated  235  men  during  the  period,  and  33 
officers  during  the  entire  war. 

"As  might  almost  a  priori  have  been  expected,  this  class 
presents  by  far  the  highest  rate  of  mortality  of  any  of  the  regional 
wounds:  55€7  per  cent  of  the  cases  treated  having  proved  fatal 
among  the  men,  and  51-5  among  the  officers.  In  fact,  where 
penetration  of  the  abdominal  cavity  by  gunshot  injury  was  con- 
sidered to  be  beyond  doubt,  death  was  the  rule,  recovery  the  rare 
exception — only  nine  patients  (including  both  men  and  officers) 
having  survived  out  of  120  where  this  was  believed  to  have  taken 
place,  and  even  of  this  small  number  some  of  the  cases  were  not 
quite  unequivocal." 

GUNSHOT  WOUNDS   OF   THE   PERINEUM  AND   GENITO-URINARY  ORGANS, 
NOT  BEING  WOUNDS   OF  THE   ABDOMEN   OR   PELVIS. 

Return  shoiving  the  number  and  results  of  cases  treated  from  1st  April, 
1855,  to  the  end  of  the  war.  (Non-commissioned  officers  and  privates 
only.} 

Total  treated 55 

{In  the  regimental  or  primary  hospitals 16 

In  the  secondary  hospitals 1 

Of  other  disease  while  under  treatment  for  wound 0 

Total  died 17 

Discharged  to  duty 28 

In  v  alided 15 

Return  showing  the  number  and  results  of  cases  treated  from  the  commence- 
ment to  the  end  of  the  war.     (Commissioned  officers  only.) 

Total  treated 4 

Total  died 0 

Discharged  to  duty 1 

Invalided 3 

GUNSHOT  WOUNDS  OF  THE  BACK  AND  SPINE. 

"  The  limits  of  this  class  are  not  very  clearly  denned.  In  this 
series,  it  has  been  made  to  include  all  lesions  of  the  spinal  cord ; 
also,  lesions  of  the  vertebral  column,  unless  they  were,  at  the 
same  time,  wounds  penetrating  the  chest  or  abdomen,  while  the 
flesh  wounds  and  contusions  have  been,  as  far  as  possible,  con- 
fined to  those  of  the  muscles  of  the  spinal  column,  strictly  so 
called :  326  of  these  injuries  have  come  under  treatment,  being 


APPENDIX. 


389 


4-6  per  cent,  of  the  total  wounded  during  the  period.  Of  these 
patients  45  died,  or  13'8  per  cent,  of  the  cases  treated ;  225  re- 
turned to  duty,  or  69  per  cent.,  while  the  remainder  were  invalided. 
Among  the  officers,  29  cases  occurred,  of  which  3,  or  10*4  per 
cent.,  were  fatal. 

"  All  the  fractures  of  the  vertebra  were  promptly  fatal,  except 
two  among  the  officers  and  two  among  the  men,  all  of  which  were 
either  fractures  of  the  transverse  processes  in  the  neck,  or  of  the 
spinous  processes  only.  Even  where  the  spinal  cord,  apparently, 
was  not  primarily  injured,  inflammation  of  it  or  its  membranes 
was  sometimes  set  up,  and  quickly  proved  fatal. 

"The  functions  of  the  spinal  cord  were  occasionally  destroyed 
temporarily  or  even  permanently,  where  no  discoverable  lesion 
existed,  probably  in  somewhat  the  same  way  as  concussion  of  the 
brain  produces  insensibility." 

GUNSHOT  WOUNDS  OF  THE  EXTREMITIES. 

Besides  the  figures  given  in  the  body  of  the  book,  the  following 
table  refers  to  the  officers  during  the  whole  war,  which  numbers 
are  not  included  in  those  previously  given  : — 

Return  showing  the  number  and  results  <J  cases  treated  from  the  commence- 
ment to  the  end  of  the,  war.      (Commissioned  officers  only.) 


^ 

£J° 

1 

•a  fc.2 

• 

3 

-  "^  ^ 

1 

I 

1 

|T  |j 

1 

'S 

•3 

a 

•I  1"^  f 

~ 

* 

1 

1 

|«l 

A 

1.  With  direct  injury  of  the  larger  arte- 

ries,  ii  M(    being  at    the   same   time 

cases  of  compound  fracture  

1 

i 

2.  With  direct  injury  of  the  larger  nerves, 

riot  being  at  the  same  time  cases  of 

compound  fracture  

1 

1 

3.  With  direct  penetration  or  perforation 

of  the  larger  joints  

10 

3 

1 

5 

1 

-I.  Of  upper  extremity,  not  included  above 

106 

4 

41 

80 

41 

•").  Of  lower  extremity,  not  included  above 

I'.IS 

10 

80 

18 

1)0 

Particulars  not  reported  

2 

2 

318 

19 

L22 

45 

2 

33* 


390 


SURGERY    OF    THE    CRIMEAN    WAR. 


"The  instances  where  wounds  of  the  arteries  have  been  suffi- 
ciently distinct  and  uncomplicated  to  warrant  their  being  kept 
separate  and  returned  under  this  head,  have  been  very  rare,  only 
two  such  being  returned  during  the  first  period,  twelve  in  the 
period  now  under  consideration,  and  one  in  an  officer." 

In  one  post-mortem  examination  of  a  case  in  which  death  took 
place  after  amputation  for  gangrene  resulting  from  wound  of  the 
foot,  the  following  interesting  condition  was  found : — 

"The  ball  was  found  to  have  passed  through  the  thigh  internally 
to  the  sheath  of  the  femoral  vessels,  which  it  had  grazed  but  not 
opened.  The  artery  at  this  point  was  slightly  contracted  for  about 
an  inch  in  length,  but  pervious,  and  contained  no  coagulum,  and 
beyond  the  contraction  its  caliber  showed  no  marks  of  inflamma- 
tion. The  vein,  however,  was  not  only  also  slightly  contracted, 
but  its  internal  surface  was  inflamed  and  filled  with  partially- 
organized  lymph,  as  far  up  as  the  entrance  of  the  deep  iliac  vein, 
and  downward  for  about  two  inches  from  the  wound.  Its  course 
was  thus  entirely  sealed,  but  nothing  like  pus  could  be  found  in 
the  femoral  or  iliac  veins,  nor  in  the  venous  system  anywhere." 

GUNSHOT  WOUNDS,  WITH  DIRECT  INJURY  OF  THE  LARGER  NERVES, 
NOT  BEING  AT  THE  SAME  TIME  CASES  OF  COMPOUND  FRACTURE. 

Return  showing  the  number  and  results  of  the  cases  treated  from  1st  April, 
1855,  to  the  end  of  the  war.  (Non-commissioned  officers  and  privates 
only.} 


Died 

^S   - 

*i 

1 

l  il 

"s 

-5-^.2 

II! 

« 

h 

""  fa  5 

3 

S^  £ 

.8 

•o 

^•a  ^ 

. 

•g 

•g  %  ° 

* 

s  >. 

a 

*  §  o 

i 

Qo 

•a 

1 

a'S. 

;ii 

•a 

1 

Dischar 

III 

Invalid 

1.  Lesion  of  brachial  or  axil 

lary  plexus            .        ... 

r 

1 

1 

9 

1 

9 

2   Lesion  of  median  nerve.. 

g 

R 

3.  Lesion  of  ulnar  nerve  

4 

1 

1 

1 

2 

4.  Lesion  of  sciatic  nerve  

5 

3 

.... 

.... 

3 

.... 

.... 

2 

5   Nerve  not  specified  ... 

2 

9 

9 

Total  

99 



— 

8 

2 



~7 

APPENDIX. 


391 


"  Only  22  such  are  returned  among  the  men,  and  one  in  an  offi- 
cer, of  which  eight  of  the  men  and  the  officer  died,  being  41  per 
cent,  of  the  cases.  There  can  be  no  question  that  many  flesh 
wounds  occurred,  in  which  nerves  of  considerable  magnitude  were 
more  or  less  implicated ;  but  as  they  were  followed  by  no  special 
evil  consequences,  they  do  not  appear  to  have  been  returned  as 
injuries  to  nerves.  Of  the  9  deaths  reported,  5  took  place  from 
tetanus  —  of  these  some  account  has  been  already  furnished — 2 
from  extensive  injury  to  upper  part  of  the  thigh,  with  lesion  of  the 
sciatic  nerve,  and  in  2  the  cause  of  death  is  not  specified." 


GUNSHOT  WOUNDS  WITH    DIRECT   PENETRATION    OK    PERFORATION    OF 

THE   LARGER  JOINTS. 

Return  showing  the  number  and  results  of  the  cases  treated  from  the  \st  of 
April,  1855,  to  the  end  of  the  war.  (Non-commissioned  officers  and 
privates  only.) 


Die 

d. 

it 

\ 

I 

In  regimental  «>r 

primary  lio.-pitals. 

|  » 

*-* 

Of  other  disease 

while  under  treat- 
ment fur  wounds. 

1 

1 

bisrliar-.'d  and  readl 
under  the  head  a 
tion  or  resection. 

C1 

1    Shoulder-joint  

17 

2 

j 

3 

14 

2    Klbow  -joint  

80 

4 

4 

20 

g 

3.  Hip-joint  

10 

3 

3 

7 

4   Knee-joint  . 

3 

13 

7 

•">     \nkle-joint  

8 

1 

1 

6 

6   Joint  not  specified  

83 

1  1 

11 

19 

3 

Total  

121 







25 



79 

17 

Return  showing  the  number  and  results  of  cases  tr  fated  from  the  com- 
mencement to  the  end  of  the  war.     (Commissioned  officers  onfy.) 


Total  trrat.'d.     Tut:il  dii-d. 

1.  Elbow-joint  ......  4  0 

2.  Knee  joint  .......  d  :', 


tc  duty. 

1 
0 


tviidmiltcd    un- 

dcr  tic-  hrad 
:iiii]iiit;itii)n     (,r 
lion. 

3 


Invalided. 

0 
1 


392  SURGERY    OF    THE   CRIMEAN    WAR. 

"Of  30  injuries  to  the  elbow  among  the  men,  and  4  among  the 
officers,  4  were  fatal  without  operation.  2  of  these  were  compli- 
cated with  injury  of  the  artery,  (1  of  the  branchial,  and  1  of  the 
ulnar,)  and  the  fatal  result  seems  to  have  been  mainly  due  to  the 
combined  effects  of  shock  and  loss  of  blood.  In  1,  extensive, 
although  individually  unimportant  injuries  coexisted — and  the 
cause  of  death  is  not  recorded  in  the  fourth.  16  primary  resec- 
tions of  the  joint,  or  of  portions  of  it,  were  performed,  and  4  second- 
ary ones;  while  6  men  were  invalided,  having  recovered  without 
operation,  with  a  varying  amount  of  stiffness  or  partial  anchylo- 
sis of  the  joint.  In  these  last,  however,  there  had  often  been  but 
little  injury  to  the  bone  inflicted;  thus  of  the  officers,  one  belong- 
ing to  the  68th  Regiment  returned  to  duty,  notwithstanding  that 
the  injury  was  followed  by  a  degree  of  stiffness  of  the  joint ;  but 
there  was  some  amount  of  doubt  as  to  whether  it  had  been  pri- 
marily opened,  although  the  ulna  in  its  immediate  neighborhood 
was  undoubtedly  injured.  In  the  remaining  instances  among  the 
officers,  the  degree  of  injury  was  such  as  to  demand  amputation. 

"Wounds  of  the  wrist-joint  have  been  returned  under  the  head 
of  injury  to  the  carpus. 

"Ten  cases  of  wound  of  the  hip-joint  are  returned.  In  3,  as 
before  mentioned,  there  had  been  such  extensive  injury  inflicted 
that  they  proved  fatal  in  a  few  hours ;  7  were  '  discharged  for 
operation ;'  one  of  which  was  for  amputation  at  the  hip-joint, 
in  a  case  in  the  34th  Regiment,  of  extensive  longitudinal  fracture 
into  the  joint ;  the  remaining  6  for  resection  of  the  head  of  the 
bone. 

"Of  wounds  of  the  knee-joint,  23  cases  are  returned  among  the 
men,  and  6  in  officers ;  6  of  these  patients  died — viz.,  3  men  and 
3  officers.  In  one  of  these  fatal  cases,  in  the  44th  Regiment,  both 
knee-joints  were  involved,  and  death  took  place  from  shock  in 
twelve  hours ;  in  another,  in  the  68th  Regiment,  it  occurred  on 
the  tenth  day,  the  result  apparently  of  inflammation  and  suppu- 
ration of  the  joint ;  and  in  the  third  from  the  same  cause,  at  a 
little  later  period.  There  can,  however,  be  no  question  but  that 
a  large  proportion  of  the  33  cases  and  11  deaths,  in  which  the 
specific  joint  involved  has  not  been  reported,  were  of  this  descrip- 
tion. The  cause  of  death  in  the  three  officers  is  not  specially 
reported." 

"The  results,  then,  as  above  given,  do  not  appear  very  encour- 


APPENDIX.  393 

aging  toward  an  attempt  to  save  the  limb  when  any  of  the  larger 
joints  (the  knee  more  especially)  is  involved,  as  we  have  seen 
that  the  recoveries  in  the  last-mentioned  injuries,  without  opera- 
tion, amounted  to  one-third  only  of  the  cases  reported.  With 
regard,  however,  to  those  of  the  upper  extremity,  no  great  harm 
appears  to  have  resulted  from  the  attempt  at  preservation,  sec- 
ondary operations  having  proved  available  without  any  large  ad- 
dition to  the  risk  of  life  by  the  proceeding.  Of  the  knee,  how- 
ever, such  cannot  be  said,  secondary  amputation  of  the  thigh 
having  proved  very  fatal.  The  amount  of  injury  done  to  the 
bone  appears  to  have  been  a  most  important  element  in  determ- 
ining the  treatment  of  such  cases.  In  none  of  the  recoveries 
from  gunshot  wounds  of  this  joint  does  the  bone  within  the  cap- 
sule appear  to  have  been  more  than  grazed,  (not  fractured ;)  in- 
deed, small  fissures  into  the  joint  often  rendered  secondary  ampu- 
tation necessary,  or  proved  directly  fatal,  as  in  the  case  of  a  man 
of  the  71st  Regiment,  accidentally  shot  in  the  street  of  Balaklava 
by  a  small  revolver  bullet.  The  missile  had  imbedded  itself  in 
the  tibia  just  below  its  tuberosity,  whence  it  was  easily  turned 
out  by  a  pointed  instrument  after  a  small  incision  had  laid  the 
site  open.  The  knee-joint  did  not  appear  to  have  been  involved, 
but  the  man  died  eight  days  afterward,  from  the  effects  of  acute 
inflammation  of  it,  and  the  accompanying  sympathetic  fever.  On 
examination  after  death,  a  minute  fissure  was  found  to  have  ex- 
tended through  the  head  of  the  tibia  into  the  joint.  The  consti- 
tution and  previous  habits  of  the  patient  also  appear  to  have  been 
of  much  importance." 

Besides  the  numbers  given  in  chapter  x.  of  gunshot  wounds 
of  the  extremities,  and  which  numbers  referred  merely  to  the 
period  subsequent  to  April  1, 1855,  the  following  occurred  among 
officers  during  the  entire  war: — 

Upper  extremity. — Flesh  contusions,  and  wounds  more  or  less 
severe,  59,  with  3  deaths ;  simple  fracture  of  long  bones,  by  con- 
tusion of  round  shot  or  shell,  3,  no  deaths ;  contusion  and  partial 
fracture  of  long  bones,  2,  and  no  deaths;  compound  fracture  of  the 
humerus,  17,  1  died  and  7  were  amputated ;  compound  fracture 
of  forearm,  5,  4  of  which  were  amputated  ;  compound  fracture  of 
radius  or  ulna  alone,  2.  There  were  7  cases  of  penetrating  or 
perforating  wounds  of  the  carpus,  4  of  which  were  amputated  or 
resected. 


394  SURGERY    OF    THE   CRIMEAN    WAR. 

Lower  extremity. — Flesh  wounds,  145  cases,  and  4  deaths,  and 
1  submitted  to  operation ;  simple  fracture  by  contusion,  2 ;  par- 
tial fracture,  2  ;  compound  fracture  of  femur,  20,  with  5  deaths 
and  10  operations ;  compound  fracture  of  tibia  and  fibula,  11,  1 
death*  and  5  operations ;  compound  fracture  of  tibia  or  fibula 
separately,  3,  with  operation.  There  were  14  cases  of  penetrating 
or  perforating  wounds  of  the  tarsus,  and  1  operation  in  conse- 
quence. 

"  Wounds  of  the  extremities  have  been  tolerably  equally  divided 
between  the  upper  and  lower  limbs,  the  preponderance  having 
been  slightly  in  those  of  the  latter;  the  resulting  mortality,  how- 
ever, has  been  very  unequal,  that  of  injuries  of  the  upper  extrem- 
ity having  been  only  2-2  per  cent.,  (exclusive  of  amputations  and 
resections,)  while  that  of  the  lower  reached  7*5  per  cent. ;  and  had 
the  results  of  the  operations  performed  been  added,  the  difference 
would  have  been  increased  in  a  very  material  degree. 

"  Epiphyses  were  sometimes  knocked  off,  in  the  upper  extremity 
chiefly ;  as  happened  to  an  officer  of  the  royal  artillery  at  the 
great  explosion  on  the  15th  November,  1855,  in,  whom  the 
epiphysis  on  the  internal  condyle  of  the  humerus  was  thus  taken 
away,  but  the  elbow-joint  not  opened ;  and  a  man  of  the  55th 
Regiment  was  struck  on  the  tip  of  the  olecranon  by  a  musket- 
ball.  A  small  portion  of  the  bone  exfoliated,  but  the  joint  re- 
mained perfect,  and  he  returned  to  duty  after  four  and  a  half 
mouths'  treatment. 

"  The  success  attending  conservative  attempts  was,  to  a  certain 
degree,  encouraging  in  the  upper  extremity,  but  in  the  lower 
sadly  the  reverse.  The  percentage  of  recoveries  in  gunshot  frac- 
tures of  the  several  bones  (neither  death  having  ensued,  nor 
amputation  having  been  resorted  to  either  as  a  primary  or 
secondary  proceeding)  is  as  follows:  Humerus,  26'6:  forearm, 
both  bones,  35-0  ;  radius  only,  70-0  ;  ulna  only.  70'0  ;  femur,  8-0; 
leg,  both  bones,  18-8  ;  tibia  only,  36-3  ;  fibula  only,  40-9." 

As  much  as  3  inches  in  length  of  the  entire  thickness  of  the 
humerus  was  removed  in  one  instance,  and  the  patient  recovered, 
with  a  useful  arm. 

"Attempts  at  preservation  of  the  limb  in  fractures  of  the  radius 
and  ulna  were  even  more  successful  than  in  the  case  of  the  hu- 
merus, as  the  percentage  of  recoveries  will  already  have  made 
apparent ;  and  it  is  remarkable  that  where  one  only  was  broken, 


APPENDIX.  395 

the  ratio  was  the  same  for  each  of  these  bones,  and  exactly  double 
that  existing  when  both  bones  had  been  fractured.  Excision  of 
portions  of  the  radius  and  ulna,  although  not  perhaps,  on  the 
whole,  so  successful,  in  respect  to  the  perfect  use  of  the  limb  re- 
tained by  the  patient,  as  those  of  the  humerus,  were  also  resorted 
to,  and  with  good  effect,  both  as  primary  and  secondary  opera- 
tions. 

"In  gunshot  compound  fractures  of  the  femur,  the  deaths  re- 
turned iu  the  table  at  page  103  only  amount  to  82  per  cent,  of  the 
cases  treated  without  operation,,  and  among  these  a  large  propor- 
tion of  limbs  torn  off  by  round  shot  are  included,  which,  as  we 
have  already  seen,  was  almost  always  a  fatal  accident,  while  the 
percentage  of  deaths  in  amputation  of  the  thigh  roaches  65'2. 
From  this  it  would  at  first  sight  appear  that  the  success  attend- 
ing attempts  at  the  preservation  of  the  limb  with  fracture  of  this 
bone  had  been  nearly  as  great  as  that  in  those  cases  where  the 
limb  was  condemned  and  removed.  It  must,  however,  be  borne 
in  mind  that  the  recoveries  without  operation  have  only  amounted 
to  14  out  of  174  cases  among  the  men,  and  5  out  of  20  among 
the  officers,  or  10  per  cent.,  and  that  all  those  selected  for  the  ex- 
periment of  preserving  the  limb  were  so  chosen  expressly  on 
account  of  the  comparatively  small  amount  of  injury  done  both 
to  the  bone  and  the  soft  parts,  and  that  even  then  recovery  was 
always  tedious,  and  the  risks  during  a  long  course  of  treatment 
numerous  and  grave.  In  many  cases,  also,  amputation  of  the 
thigh  was  performed  because  death  was  otherwise  evidently  inev- 
itable, and  it  was  thought  right  the  patient  should  be  allowed  the 
benefit  of  the  chance,  however  small,  afforded  by  operation.  By 
this  means  the  number  of  deaths  among  the  operations  is  swelled, 
while,  at  the  same  time,  the  number  of  deaths  due  to  the  fracture 
is  by  so  much  diminished,  and  the  percentage,  therefore,  tells 
doubly  in  favor  of  treatment  without  operation. 

"  On  account  of  the  very  indifferent  success  of  amputations  of 
the  thigh,  a  trial  was  made  of  resection  of  portions  of  the  shaft 
of  the  bone;  but  no  success  attended  the  experiment,  every 
case,  without  exception,  having  proved  fatal  where  this  was 
attempted." 

There  were  only  7  sword  and  lance  wounds  received  after 
April  1,  1855,  and  1  death  therefrom :  2  were  of  the  head,  and  1 
died  :  1  of  the  face,  1  of  the  perineum,  1  of  the  back,  and  '2  of  the 


396 


SURGERY    OF   THE   CRIMEAN   WAR. 


lower  extremities.  During  the  same  period,  36  bayonet  wounds 
were  received,  and  four  died  therefrom :  1  was  of  the  head,  and 
was  fatal ;  one  of  the  face ;  11  of  the  chest,  2  of  which  were 
mortal ;  2  were  of  the  abdomen ;  2  of  the  back ;  3  of  the  upper 
and  13  of  the  lower  extremity ;  1  had  numerous  such  wounds ; 
and  in  2  the  site  was  not  specified.  Among  the  officers  during 
the  war,  3  sword  and  lance  wounds,  2  bayonet  wounds  of  the 
abdomen,  and  8  of  the  lower  extremity  are  reported,  with  no  fatal 
result  therefrom. 

The  following  table  gives  the  number  of  cases  of  amputation 
and  resection  in  officers  during  the  entire  war.  These  numbers 
were  not  included  in  those  given  in  chapter  xii.,  which  referred 
merely  to  the  men. 

Return  showing  the  number  and  results  of  cases  treated  from  the  com- 
mencement to  the  end  of  the  war.     (Commissioned  officers  only.) 


1 

"rt 

1 

'S 

1 

Invalided. 

f  Shoulder-joint 

6 

2 

4 

1 

0 

4 

4 

1  Thumbs 

9 

1 

1 

6 

6 

2 

2 

(  upper  third. 
Lower  extremity..  \  Thigh  \  middle    " 
(lower      " 

5 
2 
5 
5 

4 

1 
3 
1 

1 
1 
2 
4 

Double  operation.  ...One  leg  and  one  foot. 

1 

1 

45 

15 

30 

"The  comparative  ratio  of  mortality  in  the  several  operations, 
between  the  men  and  the  officers,  is  slightly  greater  among  the 
former;  thus  the  ratio  per  cent,  of  cases  of  the  amputation 
treated  is  as  follows : — 


APPENDIX.  39f 

Mon.  Officers. 

Double  operations 50-0  

Toes 

Medio  tarsus 14-3 

Ankle 1G-G  * 

Legs .%•«  20-0 

Knee-joint 55-5 

Thigh,  lower  third 56-6  60-0 

Thigh,  middle  third 60-0  50-0 

Thigh,  upper  third 87-1  80-0 

Hip-joint 100-0  100-0 

Fingers  and  thumbs,  etc 0-9  12  5f 

Forearm 6-0  

Arm 26-4  11-3 

Shoulder  joint 33-4  33-3 

"It  is  difficult  to  assign  a  reason  for  this  difference  with  any 
degree  of  certainty." 

"And  the  following  will  show  the  results  of  the  operations 
received  for  treatment,  and  performed  at  Scutari  during  the  por- 
tion of  the  first  period  named  therein,  beyond  which  time  it  is 
regretted  that  this  distinctive  table  was  not  kept  up;  but  it  is 
known  that  very  few  operations  indeed  were  performed  there  after 
the  end  of  November. 

"  The  ratio  of  mortality  shown  in  it  from  primary  operations 
appears  very  disproportionately  small,  from  the  number  received 
for  treatment  having  been  reduced,  first  by  deaths  in  the  field 
hospitals,  and  secondly  by  deaths  on  board  ship,  during  the  pas- 
sage to  the  Bosphorus;  the  particulars  of  which,  for  the  indi- 
vidual operations,  as  before  stated,  cannot  now  be  arrived  at,  but 
the  rate  of  mortality,  upon  the  gross  total  of  primary  operations 
performed,  appears  slightly  to  have  exceeded  50  per  cent,  show- 
ing that  what  was  advanced  in  the  first  section  of  this  report,  as 
the  general  opinion  among  the  army  medical  officers,  as  to  the 
cases  of  the  first  period  having  suffered  severely  by  carriage  in 
the  Crimea  and  on  the  voyage  to  the  secondary  hospitals,  was 
well  founded,  as  primary  operations  in  the  second  period  only 

*  None  done. 

f  One  death  took  place  under  peculiar  circumstances  of  constitu- 
tion; and  as  the  number  of  cases  is  small  among  the  officers,  the 
rate  of  mortality  is  thus  unduly  increased. 

34 


393 


SUllGEUY    OE    THE    CRIMEAN    WAR. 


show  a  mortality  of  35  per  cent.,  (operations  on  fingers  and  toes 
being  excluded  in  both.)  The  ratio  in  secondary  amputations 
appears  to  have  been  on  the  whole  nearly  the  same  as  obtained 
in  the  series  of  the  second  period,  as  recorded  on  the  preceding 
page." 

Return  of  the  number  and  results  of  amputations  and  resections  treated  in 
the  hospitals  on  (he  Bosphorus  from  the  26th  September  to  the  '21th  of 
November,  1854. 


Primary. 

Secondary. 

I 

2 

| 

H 

6 
44 
14 

1 

Q 

1 
2 

Remained  under 
treatment. 

Invalided  to  Eng- 
land. 

:  4-  ~  1  Ratio  of  mortal  i- 
•  o't  6i  \  ty  per  cent. 

13 
1 

3 

i 

fi 

1  Remained  under 
treatment. 

Invalided  to  Eng- 
land. 

ll 

I  » 

ifa 

•2-i? 
"S 

K 

~  Amputations  of 

Upper 
ex-      -I 
tremity. 

Lower 
ex- 
tremity. 

DouMe 
opera-   - 
tions. 

cctions  of- 

Shoulder-joint... 
4rm.... 

2 
17 
3 
1 
11 
6 

3 
25 
11 
1 
25 
24 
1 

'" 

i 

3 
2 

3 
1 

4 
4 
1 

30-0 

28-7 

Forearm  

Hand  at  wrist... 
Thigh 

•2 
44 
35 
1 

...„. 
•    5 

18-2 
14-3 

33 
13 

27 
9 

1 

2 

5 
2 

81-8 
69-2 

IjCfJ  

Mcdio  tarsus  
!  Tar  so    metatar- 

2 
1 

1 



1 
1 

50-0 

1 

1 

Head  ofhumorns 
El  bow  -joint 

2 
2 

1 




1 

2 

50-0 

1 

1 

100 

154 

~IT 

17 

96 

11-6 

65 

"42" 

7 

16 

64-6 

It  seems  that  amputation  at  the  hip  was  14  times  performed  in 
our  army,  in  place  of  10  times,  as  stated  in  the  text ;  and  as  the 
result  was  always  fatal,  this  goes  still  further  to  strengthen  the 
deductions  made  in  chapter  xii.  The  patient  who  survived 
longest  only  lived  36  hours. 

"  In  concluding  this  report  on  the  surgical  practice  of  the  late 
war,  it  may  not  be  improper  to  notice  that  the  number  of  wounds 
and  injuries  treated,  as  set  forth  in  the  General  Return  A  of  Sick 
and  Wounded,  exceeds  very  considerably  that  herein  given ;  the 
former  (among  non-commissioned  officers  and  privates)  being 
18,283;  the  latter  11,515  only.  This  apparent  discrepancy  arises 
from  the  general  return  embracing  all  admissions  for  mechanical 
injuries,  including  kicks  from  horses,  accidental  cuts  and  bruises, 


APPENDIX.  399 

and  the  innumerable  minor  accidents  to  which  the  soldier,  in  com- 
mon with  all  working1  men,  is  exposed,  by  which  he,  like  them,  is 
occasionally  for  a  time  disabled,  and  of  which  it  has  not  been 
thought  necessary  in  this  report  to  enter  into  a  detailed  account ; 
while  the  smaller  number  is  confined  to  wounds  and  injuries,  either 
actually  received  in  action  with  the  enemy,  or  strictly  analogous 
in  nature." 

"Something  under  G  per  cent,  of  the  strength  then  would  seem 
to  indicate  the  limit  beyond  which  reserved  hospital  accommoda- 
tion need  not  be  kept  for  the  reception  of  the  wounded  of  a  large 
army  engaged  in  active  field  operations,  while  it  is  equally  plain 
that  much  under  5  per  cent,  would  not  be  safe. 

"  It  is  scarcely  necessary,  however,  to  observe  that  the  propor- 
tion of  wounded  in  any  individual  member  of  the  component  parts 
of  a  lager  force  may  be  very  widely  different  from  that  here 
stated;  thus,  at  the  battle  of  Inkerman.  the  41st  and  '.).">th  Ilegi- 
ments,  with  a  strength  in  the  Crimea  of  (17s  and  ;»oo  respectively, 
received  into  hospital  for  treatment  104  and  120  cases  of  wounds, 
or  15*3  per  cent,  of  the  strength  in  the  former,  and  24-0  in  the 
latter,  and  even  these  numbers  appear  to  have  been  exceeded  in 
some  corps  on  other  occasions. 

"  It  is  also  of  some  importance,  as  bearing  upon  the  number  of 
recruits  necessary  to  be  sent  out  to  keep  an  army  in  the  field  at 
a  given  strength,  to  ascertain  with  accuracy  the  average  number 
of  any  given  series  of  men  disabled  by  wounds  received  in  action 
who  return  to  duty  as  effective  soldiers,  and  the  average  time 
they  remain  under  treatment  before  this  result  is  obtained. 

•'  With  regard  to  the  first  period  into  which  the  campaign  has 
been  divided  in  this  report,  43'5  per  cent,  of  the  men  returned  to 
duty.  The  information  on  the  second  of  these  points,  however,  is 
defective,  for  several  reasons,  and  the  time  itself  was  subject  to 
disturbing  agencies  of  various  kinds,  which  did  not  affect  the 
series  of  wounds  of  the  second  period.  During  the  first,  also,  a 
much  larger  percentage  of  cases  treated  was  invalided  to  Eng- 
land, viz.,  37-1,  against  23*3  in  the  second.  The  cause  of  this  was 
not.  so  much  the  greater  severity  of  the  wounds  received,  or  the 
less  successful  treatment,  as  the  pressure  on  the  hospitals  during 
the  winter  of  1851,  which  led  to  the  transfer  home  of  all  cases  fit 
to  be  removed,  which  were  likely  to  require  a  lengthened  period 
of  convalescence  before  they  could  be  pronounced  fully  fit  to  re- 


400  SURGERY    OP   THE    CRIMEAN    WAR. 

sume  the  duties  of  a  soldier  on  active  service.  During  the  latter 
period,  as  before  stated,  7161  wounded  men  were  received  for 
treatment,  of  whom  4509  returned  to  duty,  or  63  per  cent.  The 
following  table  exhibits  the  time  at  which  this  result  took  place 
in  6359  of  the  cases,  of  which  number  4015  returned  to  duty. 
The  information  cannot  be  given  for  the  entire  series,  as  it  has 
not  been  furnished  by  a  few  corps,  but  the  proportion  known 
is  so  large  that  for  practical  purposes  it  seems  sufficient : — 

Number     Ratio  per  cent, 
treated,   returned  to  duty 

Total  of  wounds  treated 6359 

Returned  to  duty  after  a  period  of  treatment : 

Under  one  week 1476  232 

Over  a  week,  but  under  one  month 1408  22-1 

Over  one  month,  but  under  two , 709  11-1 

Over  two  months,  but  under  three 263  4-1 

Over  three  months,  but  under  four 101  1-6 

Over  four  months,  but  under  five 40  0-6 

Over  five  months,  btit  under  six 11  0-1 

Exceeding  six  months 7  0-1 

Total  returned  to  duty 4015  63-1 

NOTE. — This  table  has  no  reference  to  men  who  were  invalided  to 
England,  and  subsequently  returned  to  duty. 

The  number  and  results  of  the  secondary  capital  operations, 
for  the  effects  of  wounds  received  in  action,  performed  in  the 
general  hospitals  in  this  country,  (exclusive  of  the  foot  guards 
and  ordnance  corps,)  will  be  seen  in  the  following  table  : — 

Number  performed.    Died. 

Amputation  of  arm 3 

"  forearm 10 

"  thigh 4  1 

leg 3 

"  toe 1 

Removal  of  diseased  bone  from  stumps 4 

Ligature  of  external  iliac  artery 1 

The  total  number  of  men  discharged  the  service  for  disabilities 
consequent  upon  wounds  received  in  action,  and  other  mechanical 
injuries  inflicted  during  the  late  war,  was  3011.  The  severaJ 
causes  are  thus  shown  : — 


APPENDIX. 


401 


Disabilities. 

£• 

I 

1 
1 

Regiments  of 
line. 

1  Ordnance 
corps. 

j 

Luxations  

1 

3 

2 

6 

Gunshot  wounds 

56 

187 

1755 

T>0 

2118 

Incited  and  punctured  wounds 

19 

11 

1 

31 

Contusions 

8 

2 

36 

13 

54 

Fractures            . 

16 

1 

54 

15 

86 

Burns        

1 

4 

5 

Amputations  

11 

54 

547 

69 

671 

11 

11 

Injuries  not  specified 

4 

5 

20 

29 

110 

245 

2426 

230 

3011 

The  proportion  discharged  for  wounds  in  the  different  regions 
was  as  follows  : — 

Gunshot  wounds  of  the  head 88 

"  "  face 106 

"  "  neck 16 

"  "  chest 71 

"  "  abdomen 10 

"  "  perineum,  etc 8 

"  "  back  and  spine 23 

"  "  upper  extremities 551 

"  "  lower  extremities 588 

"  "  lower  joints 66 

"  "  artery 1 

"  "  nerves 14 

Sword,  bayonet,  and  lance  wounds 21 

Miscellaneous 70 

Total 1G33 

To  this  add  464  cases  of  amputation  in  the  upper,  and  179  in 
the  lower  extremity,  also  23  cases  of  resection  of  the  joints  of  the 
upper,  and  1  of  the  head  of  the  femur. 

The  account  of  the  cases  of  resection  of  the  head  of  the 
humerus  and  elbow,  when  they  were  invalided  at  Chatham,  is  not 
very  encouraging. 


402  SURGERY    OP   THE   CRIMEAN    WAR. 

The  Alma  and  the  minor  affair  at  the  Bulgaria  gave  73  offi- 
cers, and  1536  wounded,  and  as  most  of  these  were  from  round 
shot  or  grape  fired  at  shot  range,  "  the  injuries  were  peculiarly 
severe,  and  numerous  operations  were  required."  The  battle  of 
Balaklava  and  the  affair  of  the  26th  of  October  gave  36  officers 
and  329  men  wounded.  The  battle  of  Inkerman  yielded  a  much 
larger  number  still,  so  that  between  these  affairs  and  the  trench 
casualties,  4434  wounded  non-commissioned  officers  and  privates, 
with  the  operations  which  resulted,  are  not  included  in  the  num- 
bers given  in  the  statistical  tables  of  the  war.  Of  these  4434 
cases,  777  died,  or  17-5  per  cent.,  while  only  981  deaths  followed 
in  the  7,161  cases  of  wounds  which  occurred  subsequently  to 
April  1,  1855,  giving  a  percentage  of  13-7. 

With  regard  to  chloroform,  it  appears  that  that  administered 
to  the  only  patient  who  died  under  it  was,  by  the  report  of  Dr. 
Maclagan,  who  examined  it,  "totally  unfit  for  use,  being  in  a 
state  of  complete  decomposition." 

TETANUS. 

It  appears  that  in  all,  5  cases  are  alone  reported  previous  to 
April  1,  1855,  while  later,  24  cases  occurred — thus  being  only 
0'2  per  cent,  of  the  wounded. 

The  following  table  exhibits  a  succinct  view  of  the  cases 
treated  in  the  Crimea : — 


APIEND1X. 


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